**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 one (1) of 108 residents right to be free from neglect as evidenced by [DATE] Resident #3 being unwilling to sleep in his room with his roommate due to Resident #1 getting in the bed with Resident #3. This resulted in the death of another resident (Resident #2) when Resident #1 laid on top of Resident #2 who was placed in the room with Resident #1. The facility's neglect to identify roommate incompatibility and provide appropriate person-centered behavioral interventions from [DATE]-[DATE] placed Resident #2 at risk, caused his death and placed other residents in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when the facility neglected to ensure appropriate services for residents with behavioral needs. The facility's failure to provide appropriate person-centered behavioral interventions resulted in Resident #1 lying on Resident #2 until death on [DATE]. On [DATE] at 10:30 AM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the IJ Templates. The facility submitted a credible Removal Plan on [DATE], in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ removed as [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed before exit. Therefore, the scope and severity for 42 CFR(s) 483.12(a)(1) - Abuse and Neglect (F600) was lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Abuse Prevention, dated 10/22 revealed: Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish Abuse may be resident -to -resident .Neglect: A failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain .Identification: Identify events, such as occurrences, pattens and trends that may constitute abuse; and determine the direction of the investigation . Review of the facility policy titled, Resident [NAME] of Rights revealed a facility resident shall have the right to a safe environment and the right to be free of abuse and neglect. Record review of the facility reported incident report that occurred on [DATE], at approximately 3:30 AM, the following information was found: the staff responded to the call light in Resident #1's room, and he was observed unclothed and lying on top of Resident #2. Licensed nurses and Certified Nursing Assistants (CNA) intervened. Resident #2's body fell to the floor and cardiopulmonary resuscitation (CPR) measures were initiated. The emergency management services (EMS), and police department were notified. EMS arrived at the facility at approximately 3:50 AM. The EMS continued CPR measures until 4:12 AM when they discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident #1, licensed nurses and CNAs. The local police took statements and confirmed Resident #2 was deceased . The local coroner arrived to examine Resident #2's body and then removed the body from the facility. A phone interview with CNA #1 on [DATE] at 3:30 PM, revealed on the early morning of [DATE] at approximately 3:30 AM she responded to the call light going off and went into the room and observed Resident #1 naked and lying on top of Resident #2 in Resident #2's bed. She stated she instructed Resident #1 to get off of Resident #2 several times, but he would not get up, so she immediately went out into the hall and yelled for the nurse to come now, and Registered Nurse (RN) #1 came in and took over. CNA #1 revealed she had not heard any noises coming from the room that night. A phone interview with CNA #2 on [DATE] at 5:36 PM revealed she was assigned to Resident #1 and Resident #2 on the early morning of [DATE]. She stated at approximately 1:30 AM she was making rounds and observed Resident #1 was lying in bed listening to music and talking to himself which was normal behavior for both residents to have conversations with themselves, and Resident #2 was asleep in his bed. CNA #2 revealed around 3:00 AM she was making rounds and walked by the room and saw Resident #1 standing naked in front of his window but did not find that uncommon because Resident #1 often slept naked, and Resident #2 was in his bed on his side and appeared asleep. She stated that around 3:30 AM she was in an adjacent room and could hear one of the staff calling for the nurse to come help because Resident #1 was on top of Resident #2. A phone interview with RN #1 on [DATE] at 7:30 AM, revealed on the morning of [DATE] at approximately 3:30 AM he was called to the room of Resident #1 and Resident #2. As he entered the room he observed Resident #1 lying naked on top of Resident #2 with only the hands of Resident #2 could be seen. Resident #1 was severely obese weighing 489 pounds and was covering his entire torso and head area. He stated he instructed Resident #1 to get up several times and when he did Resident #2 fell off the bed, on to the floor on his back and was not breathing. Resident #2 was a full code and CPR was immediately started, EMS was called and CPR was continued but was unable to revive Resident #2. RN #1 stated he asked Resident #1 what his date of birth and social security number were and Resident #1 answered correctly. When asked what he was doing, Resident #1 said, we were arguing and fighting I went to the nurses station and asked to call the police but we would not let him, he went back to his room and continued to argue and said Resident #2 said I am going to kill you, I took offense to that so I hit him and got on top of him. RN #1 confirmed at no time during the shift did he see Resident #1 come to the nurse's station asking to call police but stated at some point Resident #1 stated he put the call light on when Resident #2 stopped fighting him. RN #1 then stated he interviewed Resident #1 after the incident and he was alert and oriented, and answered questions appropriately. He followed RN #1's command when he asked Resident #1 to go in the bathroom and he stayed when the CPR was started. RN #1 stated Resident #1 is alert and oriented most of the time, with frequent episodes of delusional episodes. He also revealed Resident #2 had frequent episodes of delusions and talking to himself. He stated he was not made aware of concerns that night, related to the residents. RN #1 then stated he has observed Resident #1 in bed with his roommates on two other occasions in the past but was not sure of the dates and confirmed it was reported to Administration by the nurses assigned to Resident #1 immediately. RN #1 revealed that the female nursing staff call him to help when some of the male residents will not respond to them. RN #1 confirmed Resident #1 was placed on one-on-one supervision after the incident but was not on any special monitoring before the incident. Review of the facility investigation interview summary with Resident #1 under facility events for the incident that occurred on [DATE] revealed, Resident #1 was interviewed but his statement was disorganized speech, delusional, and at times nonsensical. Resident #1 told the nurse that he tried to use the phone at the nurses' station to call police before the incident but, the staff denied that he was at the nurse's station or requested to use the phone. During an interview with the Executive Director/Administrator, Director of Nursing (DON), and Regional Nurse Consultant they revealed that Resident #1 did not verbalize that he had called or tried to call the police before the incident. The information gathered from Resident #1 was that Resident #2 was tormenting him. Resident #1 said he got scared and went into the bathroom where he waited. After some time waiting in the bathroom, he said he wasn't going to wait for Resident #2 to Choke my neck. According to Resident #1 he came out of the bathroom, then he said he hit Resident #2 multiple times on the head area. Initially, Resident #1 stated he hit Resident #2 once in the back of the head when he came out of bathroom before grabbing him. Resident #1 stated they tussled and wrestled for a while on the bed where Resident #2 was bear hugging him and scratching and biting him. Resident #1 said as he was holding Resident #2 on the bed, and then Resident #2 gave up after he got on top of him. Resident #1 stated that he pressed the intercom for (staff) help. He stated that he held him down until staff could come to the room. Resident #1 also stated that he had called his dad who was working and that the police came and got his body. The resident at times rambled with disorganized speech and delusions. Resident #1 had increased delusions every time he was asked to recall the event even though there were times when his statements were consistent. An interview with the Attorney General officer on [DATE] at 1:40 PM revealed he interviewed Resident #1 on [DATE] while Resident #1 was sitting in his chair in his room and he pointed to Resident #2's bed and stated, I killed him right over there on that bed I smothered his nose. The Attorney General officer also revealed he notified the facility on [DATE] that the sheriff's office would be picking Resident #1 up to meet with mental health services. Record review of an incident report dated [DATE] at 3:30 AM by Licensed Practical Nurse (LPN) #1 for Resident # 1 revealed, Incident description: Resident was observed lying on top of his roommate Resident #2, Resident #1 was redirected by RN #1 to go to the restroom. Resident #1 was assessed to have a scratch to his right interior shoulder measuring five inches by 0.4 inches and an abrasion to the last digit on his left hand measuring 0.2 inches by 0.2 inches. Immediate actions: Resident placed on 1-1 supervision. Mobility: Ambulates independently. Record review of the incident report dated [DATE] at 3:30 AM by LPN #1 for Resident #2 revealed Resident #1 was found on top of Resident #2. Resident #2 was not responding to name being called loudly, no movement, CPR was started until the EMT arrived and continued CPR. Unable to obtain vital signs, no pulse noted, code call stopped at 4:12 AM. Resident #2 was observed to have ½ inch circular abrasion to his lower right eye and his nose was misshapen. Coroner was on site and pronounced Resident #2 expired at 4:12 AM and the body was released to the Coroner. Family, responsible party, medical provider, DON and Executive Director were notified. Record review of the Behavior/Intervention Monthly Flow record for [DATE] for Resident #1 revealed behaviors to be monitored were physically/fighting aggressive, verbally aggressive (cursing), delusional, easily agitated, refusing care, and socially inappropriate with females (touching and remarks) with only one day of documentation of monitoring for the month of May which was on [DATE] and revealed no behavior noted. There was no behavior monitoring for the behavior of getting into other resident's beds. Record review the departmental note for Resident #1 revealed a note by LPN #3 dating back to [DATE] at 2:25 AM that read CNA #4 who was assigned to Resident #1 reported during her rounds Resident #1 was noted lying in bed bedside his roommate, Resident #3. Resident #1 stated he was trying to keep his roommate warm. CNA #4 reported she did not see Resident #1 do anything wrong. LPN #1 informed Resident #1 he could not get into bed with other residents. Resident #1 stated okay I was just trying to help him. The (ED) Executive Director/ Administrator, social services, and DON were notified. A phone interview with LPN #3 on [DATE] at 7:00 AM revealed she was assigned to Residents #1 and #3 on the early morning of [DATE]. She revealed CNA #4 was working the hall that night and informed her that while she was making rounds, she observed Resident #1 lying in bed with his roommate Resident # 3. Resident #3 is a deaf mute, she stated CNA #4 told her that both residents were fully clothed. LPN #3 stated that she did not think anything about it because when she asked Resident #1 why he was in the bed with Resident #3 he told her he thought that was his son and wanted to keep him warm. She stated she and CNA #4 made statements and notified the Director of Nursing and the Social Services, but she was unaware if the incident was reported and confirmed that Resident #3 was assessed and had no visible injuries. She also confirmed she did not increase monitoring of Resident #1 or notify the provider because it just did not cross her mind that Resident #1 could have attempted to abuse Resident #3 and stated, I see now why I should have recognized that. Record review of the departmental note for Resident #1 by Social Service #1, dated [DATE] at 2:14 PM revealed the writer was informed by a nurse that a CNA reported to her she observed resident lying in bed with his roommate: resident stated he was trying to keep his room-mate warm. CNA reported she did not see the resident doing anything. Resident #1 was counseled by social services and Resident #1 voiced understanding and will observe for any further behaviors. Record review of the progress notes for Resident #1 revealed a note by LPN #2 on [DATE] at 1:22 AM that Resident #1 was observed in Resident #3's bed unclothed, refusing to get in his bed stating, there are rats over there, after multiple failed attempts to redirect resident, he finally put his mattress on the floor and laid down. A phone interview with LPN #2 on [DATE] at 5:00 PM, revealed she was assigned to Resident #1 and Resident #3 on the early morning of [DATE]. During rounds she found Resident #1 lying naked in the bed with his roommate, Resident #3, and confirmed Resident #1 had to be instructed several times to get up before he would, stating there were rats on his side of the room. She stated he finally got up and put his mattress on the floor and settled down. She revealed Resident #3 was severely cognitively impaired, a deaf mute and would not be able to call for assistance. She stated Resident #3 had a shirt and brief on at the time of the incident and was assessed to have no visible injuries. LPN #2 confirmed she notified the social worker, Administrator, the DON and confirmed she did not increase monitoring or supervision of either Resident #1 or #3 and did not notify the provider of the behavior. LPN #2 also revealed on the early morning of [DATE] she observed Resident #1 in another bed with no resident in the room and stated he did not want to go to his room because there were spiders in the room. A document provided by Social Services #1 revealed Resident #3 resided with Resident #1 from [DATE]-[DATE]. Record review of the departmental notes for Resident #3 revealed a note by LPN #3 dated [DATE] at 12:25 AM that CNA #4 had reported Resident #3's roommate was noted lying in the bed with him. Record review of the departmental notes for Resident #3 revealed a note by Social Service #1 a follow up visit related to roommate lying in bed with him. Resident is a deaf-mute unable to interview due to cognitive impairment but has not had any changes in mood, behavior, cognition or daily routine. Record review of the Face Sheet revealed the facility admitted Resident #3 on [DATE] with the diagnoses of Deaf non-speaking and Autistic disorder. Review of the departmental notes for Resident #3 revealed a note by Social Service #1 dated [DATE] at 11:09 AM that Resident #3 is being moved to another room related to roommate incompatibility. An interview with the Social Service #1 assigned to the [NAME] wing on [DATE] at 1:00 PM, revealed she was informed of the incident on [DATE] when Resident #1 was observed in Resident #3's bed. She stated that Resident #1 was clothed at the time of the incident, and she counseled him not to do that again. She stated she felt Resident #1 meant no harm because he said he thought Resident #2 was his son and was trying to keep him warm and was at times delusional. She stated she did not update Resident #1's plan of care or increase monitoring and confirmed she did not recognize this as a behavior. Social service #1 also confirmed that by not updating Resident #1's plan of care, the Interdisciplinary team not putting interventions in place to alert staff and potentially protect the residents in the facility. All residents were at risk. Resident #1 did not have increased monitoring, was ambulatory, very obese, and could have gotten into to any resident's bed, placing them at risk to be accidentally hurt or abused. Social Service #1 revealed she was not aware of the incident that occurred on [DATE], in the early morning hours, when Resident #1 was observed unclothed in Resident #3's bed. When asked if increased monitoring or treatment was put in place she stated she did not put any new interventions or monitoring in place because that was nursing's responsibility. An interview with the [NAME] President of Operations on [DATE] at 2:00 PM, revealed that the previous DON and Administrator were let go from the company on [DATE] and she was not able to find any investigations for the Resident #1 related incidents in November and December. She revealed she was unable to find any 1-1 supervision/ monitoring for Resident #1 for the Month of November and [DATE]. She provided one document of 1-1 supervision for Resident #1 that was initiated after the death of Resident #2 on the morning of [DATE]. She also confirmed that she could not find evidence were Resident #1's behavior interventions or increased monitoring were ever updated after the incidents in November and [DATE] and confirmed that the potential was there for the other residents in the facility to be at risk for harm such as being smothered if Resident #1 got into their bed. She also confirmed after review of Resident #1's Behavior/Intervention Monthly Flow Record that staff were not completing the forms correctly and it appeared the resident was not monitored for behaviors. No increased monitoring forms were provided to the SA from the facility for Resident #2 or Resident #3. An interview on [DATE] at 8:00 AM, with the previous Administrator whose last date of employment was [DATE] revealed she was not aware of any incidents of Resident #1 getting in the bed with another resident naked or clothed. She stated she would have reported and investigated it immediately because it could have been abuse and the residents in the facility are all vulnerable adults. An interview on [DATE] at 8:30 AM, with the previous DON whose last date of employment was [DATE] revealed no one had ever reported Resident #1 getting into bed with his roommate. She stated if she had that information, she would have reported it immediately and measures in place to protect both residents. An interview with the current DON on [DATE] at 9:30 AM, revealed she was not aware of Resident #1's behavior of getting into other residents' beds and was not employed at the facility during the time of the first two incidents. She confirmed the incident on 11/23 and 12/23 should have been thoroughly investigated, and interventions put in place to protect the residents. She went on to say that if after the first incident on 11/23 Resident #3, should have been moved, interventions put in place and there may not have been another incident with Resident #1 getting into resident's beds. The DON also confirmed Resident #1 should have been placed on 1-1 observation and the plan of care should have been updated for staff to be aware of the behavior to possibly intervene. An interview with the Medical Director on [DATE] at 3:00 PM revealed the facility notified him of the incident on [DATE] related to the resident-on-resident death, but confirmed he was never notified of Resident #1 ever getting into any other residents' bed clothed or unclothed. An interview with the psychiatric Nurse Practitioner (NP) on [DATE] at 3:30 PM, confirmed she was informed of the incident on [DATE] related to the death of Resident #2 but revealed she was not aware of Resident #1 getting into another resident's bed. She stated that she was aware of Resident #1's delusional/hallucinations. Record review of the psychiatric encounter notes for Resident #1 dated [DATE], [DATE], and [DATE] revealed no mention of the behavior of getting into other resident beds. An interview with the current Administrator/Executive Director on [DATE] at 8:00 AM, revealed all the incidents related to Resident #1 getting into his roommate's bed should have been thoroughly investigated. Record review of the Face Sheet the facility admitted Resident #1 on [DATE] with the diagnoses of Unspecified Mood Affective Disorder, Unspecified Psychosis, and Anxiety disorder Record review of the quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that he was severely cognitively impaired. Section E- Mood revealed no behaviors checked. Section GG-Functional Abilities and Goals revealed resident was independent with walking. Section K-Swallowing/Nutritional Status revealed a height of 76 inches and weight of 486 pounds. Record review of the Face Sheet revealed the facility admitted Resident #2 on [DATE] with the diagnoses of Unspecified mood affective disorder, Unspecified psychosis, and Generalized anxiety disorder. Record review of the quarterly MDS Section C with an ARD on [DATE], revealed that Resident #2 had a BIMS score of 9 which indicated that he was moderately cognitively impaired. Review of the Mortician Record/Record of Death for Resident #2 dated [DATE] time of death was 4:12 AM, body was released to local Coroner's office. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Summary of events: The facility was informed by the state agency on [DATE] at 10:30 AM of five immediate jeopardies. The state agency provided the facility with IJ template for F600, F609, F657, F689 and F742. On [DATE], Resident #1 was clothed and observed in bed with Resident #3. Resident #3 was a vulnerable, deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for this behavior. [DATE], Resident #1 was observed in Resident #3 bed unclothed. Resident #3 was a vulnerable deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for the behavior. On [DATE], at approximately 3:30 AM, the staff responded to the call light in Resident #1's room, and he was observed unclothed and lying on top of Resident #2. licensed nurses and certified nursing assistants intervened. Resident #2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) were initiated. The emergency management services (EMS), and police department were notified. EMS arrived at the facility at approximately 3:50 AM. The emergency management services continued cardiopulmonary resuscitation measures until 4:12 AM and discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident # 1, licensed nurses and certified nursing assistants (CNA). The local police took statements and confirmed Resident # 2 was deceased . The local coroner arrived to examine Resident # 2's body and removed the body from the facility with the understanding that an autopsy would be completed to determine the final cause of death. Corrective Actions: 1. On [DATE] Resident #1 was placed on one-on- one (1-1) supervision immediately. Psychiatric placement was initiated on [DATE] at approximately 8:00 am but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner on [DATE] at approximately 12:00 PM. Resident #1 remained on 1-1 supervision until he was discharged to the custody of the local police department on [DATE] at 3:45 PM. 2. The Administrator presented to the facility on [DATE] at approximately 4:40 AM and initiated an investigation with assigned licensed nurses and certified nursing assistants. 3. On [DATE] The Administrator notified the MS State Department of Health at 5:50 AM, Attorney General Office at 9:00 PM and Ombudsman on [DATE] at 11:08 AM. 4. An in-service was initiated for all staff on [DATE] at approximately 5:30 AM regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors. 5. A special resident council meeting was conducted on [DATE] 11:30 AM by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility. 6. On [DATE] at approximately 3:30 PM, the social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates. 7. On [DATE] an in-service was initiated at approximately 10:00 am by the [NAME] President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining 1-on-1 supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received. 8. On [DATE] at 9:00 AM, the [NAME] President of Operations in serviced the Administrator and Director of Nurses on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies. 9. On [DATE] at 10:15 AM, the [NAME] President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored. 10. On [DATE] at approximately 11:30 AM, an interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns. 11. A 100% audit was initiated on [DATE] at 1:30 PM by the social services department to ensure that all Residents had compatible roommates. No issues identified. 12. A 100% audit was conducted on [DATE] at 2:00 PM by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place. 13. The Administrator reported the [DATE] incident involving Resident #1 and Resident #3 to the Mississippi State Department of Health at 2:13 PM on [DATE]. 14. An emergency quality assurance committee met on [DATE] at 2:50 PM. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional [NAME] President. The facility discussed the current survey IJ outcomes. 5 IJ were cited for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident #1 had previous behavioral issues on [DATE] with Resident #3. Resident # 1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified as of [DATE] to include protecting residents from others who get into their beds by intervening and providing 1-on-1 supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required. 14. The Ombudsman was notified of the [DATE] on [DATE] at 3:27 PM by the Administrator. 15. The Administrator reported the [DATE] incident involving Resident #1 and Resident # 3 to the Attorney General Office online system on [DATE] at 3:40 PM. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE] and the Immediate Jeopardy was removed [DATE]. Validation: The SA Validations were made onsite during the complaint investigation CI MS #25192. On [DATE], the SA validated through interviews and record reviews that all corrective actions had been taken by the facility to remove the IJ and the IJ was removed on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, care plan review, record review, and facility policy review, the facility failed to revise a comprehensive care plan related to behaviors for (1) one of 13 residents reviewed for care plans. Resident #1 The facility's failure to revise Resident #1's care plans with appropriate interventions related to his known behavior of getting into bed with other residents resulted in staff not having access to preventative measures to deter this behavior. On [DATE], Resident #1 was found in bed on top of Resident #2 with only his hands visible beneath Resident #1. Resident #2 was unresponsive and did not respond to life sustaining measures and was pronounced dead. This placed the residents residing in the facility at risk, and in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) on [DATE], which began on [DATE] when the facility failed to revise Resident #1's behavior care plan. On [DATE] at 10:30 AM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and provided the IJ Template. The facility submitted a credible Removal Plan on [DATE], in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.21(b)(2)(iii) Care plan Timing and Revision Care Plans (F657) - Scope and Severity - J, was lowered from an J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy titled, Comprehensive Person Centered Care Plans, revised 3/18, revealed: Policy: 9.) Upon a change in condition, the comprehensive person-centered care plan will be updated .' Record review of the Care Plan for Resident #1 with a problem onset date of [DATE] revealed, Problem/Need I am delusional, easily agitated, verbally/physically aggressive at times, refuses care (showers, shaves, and personal hygiene) and socially inapp. (inappropriate) with females staff (touching and remarks). Takes mattress off bed puts mattress on floor and sleeps on it . The care plan did not include a revision to the problem/need or approaches to address the behavior of Resident #1 getting into other resident's beds. Record review of the Departmental Notes for Resident #1 revealed a note by Licensed Practical Nurse (LPN) #3 on [DATE] at 2:25 AM revealed CNA #4 reported while she was making rounds Resident #1 was noted lying in bed bedside his roommate. Record review of the Departmental Note for Resident #1 revealed a note written by LPN #2 on [DATE] at 1:22 AM that Resident #1 was observed in Resident #3's bed unclothed, refusing to get in his bed stating, there are rats over there, after multiple failed attempts to redirect Resident #1 he finally put his mattress on the floor and laid down. In an interview and record review with Social Service #1 assigned to the [NAME] wing on [DATE] at 1:00 PM, she revealed she did not update Resident #1's plan of care or increase monitoring. Social service #1 also confirmed that by not updating Resident #1's plan of care and the Interdisciplinary team not putting interventions in place to alert staff and potentially protect the residents in the facility, all residents were at risk because Resident # 1 did not have increased monitoring and was ambulatory, very obese, and could have gotten into to any residents bed placing them at risk to be accidentally hurt or abused. Social Service #1 confirmed after review of Resident #1's behavior plan of care that it had never been updated to reflect the behavior of Resident #1 getting into other resident's beds and confirmed by not increasing monitoring and supervision of Resident #1's behaviors the facility did not protect the other residents from harm. Social Service #1 revealed the purpose of the care plan is to aid staff to provide person-centered care and treatment to meet the resident's specific needs. In an interview with the current Director of Nurses (DON) on [DATE] at 9:30 AM, she confirmed Resident #1 should have been placed on 1-on-1 observation and the plan of care should have been updated for staff to be aware of the behavior to possibly intervene. In an interview with the current Administrator on [DATE] at 8:00 AM, he revealed all the incidents related to Resident #1's behavior of getting into his roommate's bed should have been updated in the plan of care. Record review of the Face Sheet revealed the facility admitted Resident #1 on [DATE] with diagnoses that included Unspecified mood affective disorder, Unspecified psychosis, and Anxiety Disorder. Record review of the quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that he was severely cognitively impaired. Section E- Mood revealed no behaviors were checked. Section GG-Functional Abilities and Goals revealed the resident was independent with walking. Section K-Swallowing/Nutritional Status revealed a height of 76 inches and weight of 486 pounds. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Summary of events: The facility was informed by the state agency on [DATE] at 10:30 AM of five immediate jeopardies. The state agency provided the facility with IJ template for F600, F609, F657, F689 and F742. On [DATE], Resident #1 was clothed and observed in bed with Resident # 3. Resident # 3 was a vulnerable, deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident # 1's care plan for this behavior. [DATE], Resident # 1 was observed in Resident #3 bed unclothed. Resident # 3 was a vulnerable deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for the behavior. On [DATE], at approximately 3:30 AM, the staff responded to the call light in Resident # 1's room, and he was observed unclothed and lying on top of Resident # 2. Licensed nurses and certified nursing assistants intervened. Resident # 2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) were initiated. The emergency management services (EMS), and police department were notified. EMS arrived at the facility at approximately 3:50 AM. The emergency management services continued cardiopulmonary resuscitation measures until 4:12 AM and discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident # 1, licensed nurses and certified nursing assistants (CNA). The local police took statements and confirmed Resident # 2 was deceased . The local coroner arrived to examine Resident # 2's body and removed the body from the facility with the understanding that an autopsy would be completed to determine the final cause of death. Corrective Actions: 1. On [DATE] Resident # 1 was placed on one-on- one (1-1) supervision immediately. Psychiatric placement was initiated on [DATE] at approximately 8:00 am, but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner on [DATE] at approximately 12:00 PM. Resident #1 remained on 1-1 supervision until he was discharged to the custody of the local police department on [DATE] at 3:45 PM. 2. The Administrator presented to the facility on [DATE] at approximately 4:40 AM and initiated an investigation with assigned licensed nurses and certified nursing assistants. 3. On [DATE] The Administrator notified the MS State Department of Health at 5:50 AM, Attorney General Office at 9:00 PM and Ombudsman on [DATE] at 11:08 AM. 4. An in-service was initiated for all staff on [DATE] at approximately 5:30 AM regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors. 5. A special resident council meeting was conducted on [DATE] 11:30 AM by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility. 6. On [DATE] at approximately 3:30 PM, the social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates. 7. On [DATE] an in-service was initiated at approximately 10:00 am by the [NAME] President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining 1-on-1 supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses were instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received. 8. On [DATE] at 9:00 AM, the [NAME] President of Operations in serviced the Administrator and Director of Nurses at 9:00 AM on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies. 9. On [DATE] at 10:15 AM, the [NAME] President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored. 10. On [DATE] at approximately 11:30 AM, an interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns. 11. A 100% audit was initiated on [DATE] at 1:30 PM by the social services department to ensure that all Residents had compatible roommates. No issues identified. 12. A 100% audit was conducted on [DATE] at 2:00 PM by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place. 13. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the MS State Department of Health at 2:13 PM on [DATE]. 14. An emergency quality assurance committee met on [DATE] at 2:50 PM. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional [NAME] President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident # 1 had previous behavioral issues on [DATE] with Resident # 3. Resident # 1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified as of [DATE] to include protecting residents from others who get into their beds by intervening and providing 1-on-1 supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required. 14. The Ombudsman was notified of the [DATE] on [DATE] at 3:27 PM by the Administrator. 15. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the Attorney General Office online system on [DATE] at 3:40 PM. The facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE] and the Immediate Jeopardy was removed on [DATE]. Validation: SA Validations were made onsite during the complaint investigation CI MS #25192. On [DATE], the SA surveyor verified through staff and resident interview, record review, sign-in sheets, and in-service reviews that all corrective actions had been taken by the facility to remove the IJ during the survey on [DATE] and the IJ was removed on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review, the facility failed to provide adequate supervision to reduce the risk of an accident/hazards when a resident with behaviors got into other resident's beds and did not have any increased supervision/monitoring put in place resulting, in the physical assault and death of a resident for (1) one of (4) four residents reviewed for accidents. (Resident #2) The facility's failure to provide adequate supervision and monitoring, placed Resident #2 and other residents residing in the facility at risk, and in a situation which caused Resident #2's death and was likely to cause serious injury, serious harm, serious impairment, or death for others. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when the facility failed to provide increased supervision/monitoring and ensure appropriate services for residents with behavioral needs. The facility's failure to provide supervision/monitoring, resulted in the physical assault and death of a resident on [DATE]. On [DATE] at 10:30 AM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the IJ Templates. The facility submitted a credible Removal Plan on [DATE], in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed before exit. Therefore, the scope and severity for 42 CFR(s) 483.25(d)(1)(2)- Free of accidents/hazards/supervision/devices (F689) Scope and Severity -J, was lowered from a J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy Accident & Incident Documentation & Investigation Resident Incident reviewed 7/18 revealed POLICY: Accidents and/or incidents involving resident care will .be analyzed for trends or patterns to enable the facility to enhance preventative measures to reduce the occurrence of incidents . Record review of an incident report dated [DATE], at approximately 3:30 AM, the staff responded to the call light in Resident # 1's room, and he was observed unclothed and lying on top of Resident #2. Licensed nurses and Certified Nursing Assistants (CNAs) intervened. Resident #2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) was initiated. The emergency management services (EMS) and the police department were notified. EMS arrived at the facility at approximately 3:50 AM. EMS continued CPR until 4:12 AM and then discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident #1, licensed nurses and CNAs. The local police took statements and confirmed Resident #2 was deceased . The local coroner arrived to examine Resident # 2's body and then removed the body. Record review of the Face Sheet revealed the facility admitted Resident #1 on [DATE] with the diagnoses that included Unspecified mood affective disorder, Unspecified psychosis, and Anxiety Disorder. Record review of the quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of [DATE], revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that he was severely cognitively impaired. Section E- Mood revealed no behaviors checked. Section GG-Functional Abilities and Goals revealed the resident was independent with walking. Section: K-Swallowing/Nutritional Status revealed a height of 76 inches and weight of 486 pounds. Record review of the Face Sheet revealed the facility admitted Resident #2 on [DATE] with the diagnoses of Unspecified Mood Affective disorder, Unspecified Psychosis, and Generalized Anxiety disorder. Record review of the quarterly MDS Section C with an ARD on [DATE], revealed that Resident #2 had a BIMS score of 9 which indicated that he was moderately cognitively impaired. On [DATE] at 7:30 AM, during a phone interview with Registered Nurse (RN) #1 revealed on the morning of [DATE] at approximately 3:30 AM he was called to the room of Resident #1 and Resident #2 and observed Resident #1 lying naked on top of Resident #2 with only the hands of Resident #2 could be seen. RN #1 revealed Resident #1 was severely obese, weighing 489 pounds, covering Resident #2's entire torso and head. RN #1 confirmed Resident #1 was placed on one-on-one monitoring after the incident, but was not on any special monitoring before the incident. Record review of the coroner report, revealed Resident #2 was pronounced deceased on [DATE] at 4:12 AM and then released to the coroner's office. Review of the Departmental Notes for Resident #1 revealed a note by Licensed Practical Nurse (LPN) #3 on [DATE] at 2:25 AM, CNA #4 reported while she was making rounds Resident #1 was noted lying in bed bedside roommate, Resident #3. Resident #1 stated he was trying to keep his roommate warm. LPN #2 informed Resident #1 he could not get into bed with other residents. Resident #1 stated, okay, I was just trying to help him. On [DATE] at 7:00 AM, in a phone interview LPN #3 revealed on the early morning of [DATE] CNA #4 that was working the hall that night informed her that while she was making rounds, she observed Resident #1 lying in bed with his roommate Resident # 3, who is a deaf mute. She also confirmed she did not increase monitoring of Resident #1 because it just did not cross her mind that Resident #1 could have attempted to abuse Resident #3 stating I see now why I should have recognized that. Record review of the Departmental Note for Resident #1 revealed a note by Social Service #1 dated [DATE] at 2:14 PM revealed the writer was informed by a nurse that a CNA reported to her, she observed Resident #1 lying in bed with his roommate: Resident #1 stated he was trying to keep his roommate warm. The CNA reported she did not see the resident doing anything. The resident was counseled by social services and the resident voiced understanding and will observe for any further behaviors. Record review of the Departmental Note for Resident #1 revealed a note by LPN #2 on [DATE] at 1:22 AM Resident #1 was observed in roommate's bed unclothed, refusing to get in his bed stating, there are rats over there, after multiple failed attempts to redirect he finally put his mattress on the floor and laid down. On [DATE] at 5:00 PM, a phone interview with LPN #2 revealed on the early morning of [DATE] she found Resident #1 lying naked in the bed with Resident #3. She confirmed she did not increase monitoring of either Resident #1 or Resident #3. On [DATE] at 1:00 PM, in an interview with the Social Service staff #1 assigned to the [NAME] wing on [DATE] revealed she was informed of the incident on [DATE] early in the morning hours when Resident #1 was observed in Resident #3's bed. Social Service #1 stated she did not update Resident #1's increase monitoring and confirmed she did not recognize this as a behavior. Social Service #1 also confirmed that by not putting interventions/increased monitoring in place to alert staff and potentially protect the residents in the facility, all residents were at risk. Due to Resident #1 was ambulatory, very obese, and could have gotten into to any resident's bed placing them at risk to be accidentally hurt. When asked if increased monitoring or treatment was put in place after the incident on [DATE], she stated she did not put any new interventions or monitoring in place because that was nursing's responsibility. Record review of the Departmental Notes for Resident #3 revealed a note by Social Service #1 dated [DATE] at 11:09 AM, that resident is being moved related to roommate incompatibility. Record review of the Face Sheet revealed the facility admitted Resident #3 on [DATE] with the diagnoses of Deaf non-speaking and Autistic disorder. On [DATE] at 2:00 PM, an interview with the [NAME] President of Operations, revealed she was unable to find any 1-1 supervision/monitoring for Resident #1 related to the incidents in November and [DATE]. She provided a document of 1-1 supervision for Resident #1 that was initiated after the death of Resident #2 on the morning of [DATE]. She also confirmed that she could not find evidence where Resident #1's behavior interventions/ monitoring were updated after the incidents in November and [DATE]. She also confirmed that the potential was there for the other residents in the facility to be at risk of harm, such as being smothered if Resident #1 got into their bed. No increased monitoring forms were provided to the SA from the facility for Resident #2 or Resident #3. Record review of the Resident Location Monitoring form for Resident #1 provided by the facility, revealed resident to only be on increased monitoring 1-on 1 supervision starting at 3:45 AM on [DATE] -3:45 PM on [DATE] when Resident #1 was released to the Sheriff's department. The facility submitted an acceptable Removal Plan for the IJ. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Summary of events: The facility was informed by the state agency on [DATE] at 10:30 AM of five immediate jeopardies. The state agency provided the facility with IJ template for F600, F609, F657, F689 and F742. On [DATE], Resident #1 was clothed and observed in bed with Resident # 3. Resident # 3 was a vulnerable, deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for this behavior. [DATE], Resident # 1 was observed in Resident #3 bed unclothed. Resident # 3 was a vulnerable deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for the behavior. On [DATE], at approximately 3:30 AM, the staff responded to the call light in Resident # 1's room, and he was observed unclothed and lying on top of Resident # 2. Licensed nurses and certified nursing assistants intervened. Resident # 2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) were initiated. The emergency management services (EMS), and police department were notified. EMS arrived at the facility at approximately 3:50 AM. The emergency management services continued cardiopulmonary resuscitation measures until 4:12 AM and discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident # 1, licensed nurses and certified nursing assistants (CNA). The local police took statements and confirmed Resident # 2 was deceased . The local coroner arrived to examine Resident # 2's body and removed the body from the facility with the understanding that an autopsy would be completed to determine the final cause of death. Corrective Actions: 1. On [DATE] Resident # 1 was placed on one-on- one (1-1) supervision immediately. Psychiatric placement was initiated on [DATE] at approximately 8:00 am but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner on [DATE] at approximately 12:00 PM. Resident #1 remained on 1-1 supervision until he was discharged to the custody of the local police department on [DATE] at 3:45 PM. 2. The Administrator presented to the facility on [DATE] at approximately 4:40 AM and initiated an investigation with assigned licensed nurses and certified nursing assistants. 3. On [DATE] The Administrator notified the MS State Department of Health at 5:50 AM, Attorney General Office at 9:00 PM and Ombudsman on [DATE] at 11:08 AM. 4. An in-service was initiated for all staff on [DATE] at approximately 5:30 AM regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors. 5. A special resident council meeting was conducted on [DATE] 11:30 AM by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility. 6. On [DATE] at approximately 3:30 PM, the social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates. 7. On [DATE] an in-service was initiated at approximately 10:00 am by the [NAME] President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining 1-on-1 supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received. 8. On [DATE] at 9:00 AM, the [NAME] President of Operations in serviced the Administrator and Director of Nurses at 9:00 AM on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies. 9. On [DATE] at 10:15 AM, the [NAME] President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored. 10. On [DATE] at approximately 11:30 AM, an interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns. 11. A 100% audit was initiated on [DATE] at 1:30 PM by the social services department to ensure that all Residents had compatible roommates. No issues identified. 12. A 100% audit was conducted on [DATE] at 2:00 PM by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place. 13. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the MS State Department of Health at 2:13 PM on [DATE]. 14. An emergency quality assurance committee met on [DATE] at 2:50 PM. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional [NAME] President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident # 1 had previous behavioral issues on [DATE] with Resident # 3. Resident # 1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified as of [DATE] to include protecting residents from others who get into their beds by intervening and providing 1-on-1 supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required. 14. The Ombudsman was notified of the [DATE] on [DATE] at 3:27 PM by the Administrator. 15. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the Attorney General Office online system on [DATE] at 3:40 PM. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE] and the Immediate Jeopardy was removed [DATE]. Validation: SA Validations were made onsite during the complaint investigation (CI) MS #25192. On [DATE], the SA surveyor verified through staff and resident interview, record review, sign-in sheets, and in-service reviews that all corrective actions had been taken by the facility to remove the IJ during the survey on [DATE] and the IJ was removed on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to recognize behaviors and provide appropriate person-centered behavioral interventions for one (1) of three (3) residents with documented behaviors resulting in the physical assault and death of a resident. (Resident #1) The facility's failure to identify behaviors and failure to provide appropriate person-centered behavioral interventions and supervision, from [DATE] through [DATE] resulted in the death of Resident #2 and placed other residents at risk, and in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when the facility failed to identify behaviors, and ensure appropriate services for residents with behavioral needs. The facility's failure to identify potential abuse, failure to provide appropriate person-centered behavioral interventions and supervision resulted in the physical assault and death of a resident on [DATE]. On [DATE] at 10:30 AM, the SA informed the Nursing Home Administrator of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) and provided the IJ Templates. The facility submitted a credible Removal Plan on [DATE], in which the facility alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ removed as of [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed before exit. Therefore, the scope and severity for 42 CFR(s) 483.40 (b)(1) Treatment/services Mental/Psychosocial (F742) - Scope and Severity - J, was lowered from an J to a D while the facility develops and implements a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility policy titled, Behavior Management and Psycho-pharmacological Medication Monitoring Protocol, reviewed 3/18, revealed: Behavioral Interventions: are individualized non-pharmacological approaches to care as a part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical or psychosocial well being . Record review of an incident report dated [DATE], at approximately 3:30 AM, revealed the staff responded to the call light in Resident # 1's room, and he was observed unclothed and lying on top of Resident #2. Licensed nurses and Certified Nursing Assistants (CNAs) intervened. Resident #2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) was initiated. The emergency management services (EMS) and the police department were notified. EMS arrived at the facility at approximately 3:50 AM. EMS continued CPR until 4:12 AM and then discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident #1, licensed nurses and CNAs. The local police took statements and confirmed Resident #2 was deceased . The local coroner arrived to examine Resident # 2's body and then removed the body. Record review of the Behavior/Intervention Monthly Flow record for [DATE] for Resident #1 revealed behaviors to be monitored were physically/fighting aggressive, verbally aggressive (cursing), delusional, easily agitated, refusing care, and socially inappropriate with females (touching and remarks). There was no documentation of Residents #1's behavior of getting into other resident's beds listed to be monitored on the flow record. There was only one day of monitoring documentation on [DATE] for the month of May. Record review of the Face Sheet revealed the facility admitted Resident #1 on [DATE] with diagnoses that included Unspecified Mood Affective disorder, Unspecified Psychosis, and Anxiety disorder. Record review of the quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that he was severely cognitively impaired. Section E- Mood revealed no behaviors checked. Section GG-Functional Abilities and Goals revealed the resident was independent with walking. Section: K-Swallowing/Nutritional Status revealed a height of 76 inches and weight of 486 pounds. Record review of the quarterly MDS Section C with an ARD on [DATE], revealed that Resident #2 had a BIMS score of 9 which indicated he had moderate cognitive impairment During a telephone interview with Registered Nurse (RN) #1 on [DATE] at 7:30 AM, confirmed on the morning of [DATE] at approximately 3:30 AM Resident #1 was placed on one-on-one monitoring but confirmed the resident was not on any special monitoring before the incident. Record review of the Departmental Note for Resident #1 revealed a note written by Licensed Practical Nurse (LPN) #3 on [DATE] at 2:25 AM, CNA #4 reported while she was making rounds that Resident #1 was noted lying in bed bedside roommate Resident #3. Resident #1 stated he was trying to keep his roommate warm. LPN #3 informed Resident he could not get into bed with other residents. Resident #1 stated, okay, I was just trying to help him. Record review of the Face Sheet revealed the facility admitted Resident #3 on [DATE] with diagnoses that included Deaf non-speaking and Autistic disorder. During a phone interview on [DATE] at 7:00 AM, LPN #3 revealed she was assigned to Resident #1 and #3 on the early morning of [DATE] and confirmed she did not increase monitoring of Resident #1 because it just did not cross her mind that Resident #1 could have attempted to abuse Resident #3. LPN #3 stated I see now why I should have recognized that. Record review of the Departmental Note for Resident #1by Social Service (SS) #1 dated [DATE] at 2:14 PM revealed, the writer was informed by a nurse that a CNA reported to her, she observed Resident #1 lying in bed with his roommate. Resident #1 stated he was trying to keep his roommate warm. The CNA reported she did not see the resident doing anything. Resident #1 was counseled by SS and the resident voiced understanding and will observe for any further behaviors. Record review of the Progress Notes for Resident #1 revealed a note by LPN #2 on [DATE] at 1:22 AM Resident #1 was observed in roommate's bed unclothed, refusing to get in his bed stating, there are rats over there, after multiple failed attempts to redirect Resident #1 finally put his mattress on the floor and laid down. During a telephone interview with LPN #2 on [DATE] at 5:00 PM, she revealed she was assigned to Resident #1 and Resident #3 on the early morning of [DATE] and confirmed she did not increase monitoring of either Resident #1 or #3 and did not notify the provider of the behavior. During an interview with the Social Service #1 on [DATE] at 1:00 PM, she revealed she was informed of the incident on [DATE], and she counseled Resident #1 not to do that again. She stated she felt Resident #1 meant no harm because he said he thought Resident #3 was his son and trying to keep him warm and was at times delusional. During a record review and interview with the [NAME] President of Operations on [DATE] at 2:00 PM, she revealed she was unable to find any 1:1 supervision monitoring for Resident #1 for the months of November and [DATE] at the time of the incidents. She provided only one document of 1:1 supervision for Resident #1 that was initiated after the death of Resident #2 on the morning of [DATE]. She also confirmed after review of Resident #1's behavior monitoring forms that staff were not completing the forms correctly, and it appeared the Resident was not monitored for behaviors. During an interview with the current Director of Nursing (DON) on [DATE] at 9:30 AM, she confirmed interventions should have been put in place for the incidents that occurred in November and [DATE] to protect the residents. She went on to say that if after the first incident on [DATE] Resident #3 was moved and interventions were put in place there may not have been another incident with Resident #1 getting into resident's beds. She confirmed Resident #1 should have been placed on 1-on-1 observation and the plan of care should have been updated for staff to be aware of the behavior to possibly intervene. The facility submitted an acceptable Removal Plan for the IJ on [DATE]. Review of the facility's Removal Plan revealed the facility took the following actions to remove the IJ: Summary of events: The facility was informed by the state agency on [DATE] at 10:30 AM of five immediate jeopardies. The state agency provided the facility with IJ template for F600, F609, F657, F689 and F742. On [DATE], Resident #1 was clothed and observed in bed with Resident # 3. Resident # 3 was a vulnerable, deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident # 1's care plan for this behavior. [DATE], Resident # 1 was observed in Resident #3 bed unclothed. Resident # 3 was a vulnerable deaf, mute male Resident. The facility failed to investigate, implement interventions, and revise Resident #1's care plan for the behavior. On [DATE], at approximately 3:30 AM, the staff responded to the call light in Resident # 1's room, and he was observed unclothed and lying on top of Resident # 2. Licensed nurses and certified nursing assistants intervened. Resident # 2's body fell to the floor and cardiopulmonary resuscitation measures (CPR) were initiated. The emergency management services (EMS), and police department were notified. EMS arrived at the facility at approximately 3:50 AM. The emergency management services continued cardiopulmonary resuscitation measures until 4:12 AM and discontinued life resuscitating measures. The local police arrived at the facility at approximately 3:50 AM and interviewed Resident # 1, licensed nurses and certified nursing assistants (CNA). The local police took statements and confirmed Resident # 2 was deceased . The local coroner arrived to examine Resident # 2's body and removed the body from the facility with the understanding that an autopsy would be completed to determine the final cause of death. Corrective Actions: 1. On [DATE] Resident # 1 was placed on one-on- one (1-1) supervision immediately. Psychiatric placement was initiated on [DATE] at approximately 8:00 am but was unsuccessful. A telehealth visit was conducted with the psychiatric nurse practitioner on [DATE] at approximately 12:00 PM. Resident #1 remained on 1-1 supervision until he was discharged to the custody of the local police department on [DATE] at 3:45 PM. 2. The Administrator presented to the facility on [DATE] at approximately 4:40 AM and initiated an investigation with assigned licensed nurses and certified nursing assistants. 3. On [DATE] The Administrator notified the MS State Department of Health at 5:50 AM, Attorney General Office at 9:00 PM and Ombudsman on [DATE] at 11:08 AM. 4. An in-service was initiated for all staff on [DATE] at approximately 5:30 AM regarding supervision of accidents and incidents, abuse/neglect, how to handle resident to resident altercations, reporting of any resident with delusional behaviors or verbalizing harmful behaviors to others, how to deal with aggressive behaviors. 5. A special resident council meeting was conducted on [DATE] 11:30 AM by the Administrator and Director of Nurses to ensure that the facility's residents felt safe. 21 out of 21 Residents verbalized feeling safe in the facility. 6. On [DATE] at approximately 3:30 PM, the social service department completed a 100% audit on roommate compatibility. 100% of the roommates were compatible or chose to be roommates. 7. On [DATE] an in-service was initiated at approximately 10:00 am by the [NAME] President of Operations for all staff on prevention/supervision of accidents, abuse/neglect, abuse reporting, resident rights, implementing interventions to prevent reoccurrence and updating care plans to reflect interventions and monitoring of behaviors. In-service details: When residents are observed in another resident's bed to immediately intervene and separate. The staff was instructed to notify the nurse immediately and protect the alleged victim by remaining 1-on-1 supervision with the alleged aggressor. The nurses were instructed to immediately perform head to toe skin assessments for both Residents while ensuring and notifying the Executive Director and Director of Nurses. The Administrator and Director of Nurses were instructed to ensure that a thorough investigation is completed and reported to the state agencies. The Administrator and Director of Nurses was instructed to ensure that interventions are put in place to protect other Residents and the alleged aggressor's care plan is updated and behavior is monitoring is in place. In-service also included notifying the nurse, Administrator, and Director of nurses immediately if any Resident verbalize or exhibits delusional behaviors that are harmful towards others. No staff will be allowed to work until the in-service is received. 8. On [DATE] at 9:00 AM, the [NAME] President of Operations in serviced the Administrator and Director of Nurses at 9:00 AM on abuse/neglect and ensuring to investigate and report all instances of abuse/neglect to regulatory agencies. 9. On [DATE] at 10:15 AM, the [NAME] President of Operations in serviced the social service department on ensuring that care plans are revised to reflect interventions and behaviors are monitored. 10. On [DATE] at approximately 11:30 AM, an interview was initiated for 28 cognitive residents to determine if they have incurred any issues with other residents lying in their beds. 28 of 28 Residents denied any concerns. 11. A 100% audit was initiated on [DATE] at 1:30 PM by the social services department to ensure that all Residents had compatible roommates. No issues identified. 12. A 100% audit was conducted on [DATE] at 2:00 PM by the social services department to ensure that Residents' behaviors are care planned and monitoring is in place. 13. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the MS State Department of Health at 2:13 PM on [DATE]. 14. An emergency quality assurance committee met on [DATE] at 2:50 PM. The attendees of the meeting were the Administrator, Director of Nurses, Assistant Director of Nurses, Social Services Assistant, Staff Development Coordinator, Nurse Practitioner, Regional Clinical Operations Nurse, and Regional [NAME] President. The facility discussed the current survey IJ outcomes. 5 IJ cites for abuse/neglect, abuse reporting, revision of care plans, behavioral monitoring, and accidents/incidents. Upon investigation, Resident # 1 had previous behavioral issues on [DATE] with Resident # 3. Resident # 1 was unclothed. The facility failed to report, investigate and implement interventions based on the behaviors. In-services modified as of [DATE] to include protecting residents from others who get into their beds by intervening and providing 1-on-1 supervision. In addition, reporting and investigating alleged events. All policies were reviewed for accidents/incidents, abuse prevention, revision of care plans, behavioral monitoring. No changes required. 14. The Ombudsman was notified of the [DATE] on [DATE] at 3:27 PM by the Administrator. 15. The Administrator reported the [DATE] incident involving Resident # 1 and Resident # 3 to the Attorney General Office online system on [DATE] at 3:40 PM. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of [DATE] and the Immediate Jeopardy was removed [DATE]. Validation: SA Validations were made onsite during the complaint investigation CI MS #25192. On [DATE], the SA surveyor verified through staff and resident interview, record review, sign-in sheets, and in-service reviews that all corrective actions had been taken by the facility to remove the IJ during the survey on [DATE] and the IJ was removed on [DATE].

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

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

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

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