Courtyard Health And Rehabilitation

jeopardy to resident health or safety

facility.

Resident # 1 remains in inpatient behavioral health facility.Once Resident #1 exited facility the fire extinguisher was mounted back securely, and the beds were placed with wheels locked to remove barricade risk was removed.On 10/12/25 the Executive Director interviewed Resident that was barricaded in room with Resident # 1 and asked if he was ok and was, he was afraid.

Resident indicated that he was not afraid.On 10/13/25 facility issued an emergency notification of discharge to residents' family at 10: 13 AM.

Social Services Director began searching for alternative placement. Resident #1 will not return to the facility until cleared and appropriate safeguards are in place.Education was initiated with all facility staff on 10/16/25 by the Director of Nursing on Abuse and Neglect Policy with emphasis on Resident's psychosocial harm, de-escalation of behavioral episodes and investigation of psychosocial harm.

Staff will be educated prior to accepting assignment.Education was conducted on 10/16/25 with the Executive Director and Director of Nursing by the Regional Director of Clinical Services on investigation post behavioral episodes for psychosocial harm of Residents.Interview with current Residents with a Brief Interview Mental Status (BIMS) or 10 or greater was conducted by the Social Services Director, Social Services Assistant, and the Assistant Director of Nursing on 10/16/25 and 10/17/25 to assess for any psychosocial harm or Incident of trauma.On 10/17/25 Residents #2, #3 and #4's Care Plans were updated to Include Trauma Centered care.Quality Assurance Performance Improvement (QAPI) Committee met on 10/17/25 at 2:00 PM.

Attendees were the Medical Director, Executive Director, Director of Nursing, Social Services Director, Minimum Data Set Nurse, Unit Manager, Business Development, Regional Director of Nursing, Medical R cords Clerk, Assistant Director of Nursing, Treatment Nurse, Infection Control Preventionist, Maintenance Director and Human Resources Director.

Abuse Neglect Policy, Behavioral Health Policy and Accidents and Supervision Policy was reviewed with no changes made.The facility alleges all corrective actions were completed on 10/17/25 and the Immediate Jeopardy was removed on 10/18/25.Corrective Actions:The Director of Nursing started an all-staff in-service on Abuse/ Neglect policy with emphasis on resident psychosocial harm and abuse de-escalation of behavioral episodes and an investigation of psychosocial harm that concluded 10/20/25.

Affected residents care plans were updated on 10/16/25 to reflect trauma informed care by the Care Plan team.The Regional Director in-serviced the Administrator and the Director of Nursing on 10/17/25 regarding Abuse/Neglect, Investigations of Psychosocial Harm, Behavioral Services, De-escalations and Accidents and Hazards.An Emergency Quality Assurance Committee was held on 10/17/25 with the following staff in attendance: Regional Director, Executive Director, Director of Nursing, MDS Nurse, Business Development Services, Social Services Director, Assistant Director of Nursing, Environmental Services, Maintenance Director and Infection Prevention Nurse.The facility completed all actions to remove the Immediate Jeopardies on 10/17/25 and alleges the IJ was removed on 10/18/25. On 10/20/25, the State Agency (SA) validations were made onsite during the complaint investigation 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 10/18/25.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Courtyard Health and Rehabilitation

501 South Locust Street McComb, MS 39648

SUMMARY STATEMENT OF DEFICIENCIES