Complaint Investigation - THE OAKS REHABILITATION AND HEALTHCARE CENTER

F-Tag F600

Harm Level: Immediate human rights., including the right to be free from abuse, neglect, mistreatment, exploitation and or

Residents Affected: Few resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided

F-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:

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 17 255261 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255261 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oaks Rehabilitation and Healthcare Center 3716 Highway 39 North Meridian, MS 39301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 A review of the facility's policy, Abuse, Neglect, Exploitation & (and) Misappropriation revised 11/16/2022, revealed .It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic Level of Harm - Immediate human rights., including the right to be free from abuse, neglect, mistreatment, exploitation and or jeopardy to resident health or misappropriation of property .Employees of the center are charged with the continuing obligation to treat safety residents so they are free from abuse . No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment and or misappropriation of property against any Residents Affected - Few resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Definitions .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical abuse includes but is not limited to . corporal punishment, which is physical punishment, is used as a means to correct or control behavior. Corporal punishment includes, but is not limited to; spanking, slapping of hands, flicking or hitting with an object. Verbal abuse .includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of age, ability to comprehend, or disability .

A review of the facility's investigation, dated 3/17/25, revealed that on Monday, 3/17/25, at 10:44 AM, the facility's Administrator found two (2) different anonymous pieces of paper on his desk that stated CNA #1 had been abusing residents. Interviews were conducted with all residents able to effectively communicate and there were no complaints on staff received from the residents interviewed. There were no obvious signs of abuse on any of the residents who were unable to communicate. Interviews with staff members that work around or directly with CNA #1 were conducted. Upon those interviews, a witness stated she was changing a resident and heard CNA #1 tell Resident #2 that if she (expletive) out the bed like she did yesterday, she was going to beat her (expletive). Another witness stated she was assisting CNA #1 with providing care to a combative resident, when she grabbed the residents nose, causing it to leak blood and told the combative resident, It how you deal with crazy (expletive) like you.

Resident #1

A record review of the Admission Record revealed the facility admitted Resident #1 on 3/08/2013 with current diagnoses including Parkinson's Disease and Dementia.

A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated her cognition was moderately impaired.

Resident #2

A record review of the Admission Record revealed the facility admitted Resident #2 on 10/3/2019 with current diagnoses including Hypertension and Major Depressive Disorder.

A record review of the Quarterly MDS with an ARD of 3/12/25 revealed Resident #2 had a BIMS score of 3 which indicated her cognition was severely impaired. Section GG revealed Resident #2 is dependent on staff for toileting hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 17 255261 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255261 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oaks Rehabilitation and Healthcare Center 3716 Highway 39 North Meridian, MS 39301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Record review of the facility's Assignment sheets, dated 3/6/25, revealed CNA #1 and CNA #3 were scheduled on the same hall on 3/7/25 at 6:20 AM. Level of Harm - Immediate jeopardy to resident health or Record review of the facility's time sheets, dated 3/6/25 through 3/7/25, revealed CNA #1 and CNA #3 safety worked the 11-7 shift and were present at the facility at 6:20 AM.

Residents Affected - Few On 04/02/25 at 11:00 AM, during an interview with CNA #3, she stated that on 03/07/25 at approximately 6:20 AM, she was working the overnight shift (11:00 PM - 7:00 AM), although her normal schedule was the 7:00 AM - 3:00 PM shift. CNA #3 explained that Licensed Practical Nurse (LPN) #1 asked her to assist CNA #1 with providing care to Resident #1, as the resident was reportedly combative. As care began, Resident #1 swung at both CNAs. CNA #3 reported that she held the resident's hands gently and reassured her, telling her everything was okay. The resident then pulled away from her grasp and grabbed CNA #1 by the hair. CNA #3 reported that in response, CNA #1 grabbed the resident's nose and twisted it upwards, which caused the resident's nose to bleed. According to CNA #3, CNA #1 then stated, This is how you deal with crazy (expletive) like you. CNA #3 recalled telling CNA #1, You can't treat and talk to her like that, and stated

she attempted to leave the room to locate the nurse but did not see her nearby. Not wanting to leave the resident alone with CNA #1, CNA #3 returned to the room and offered to finish providing care. She stated that CNA #1 appeared to ignore her and refused to leave the room. CNA #1 continued providing care, cleaned the blood from the resident's face using the resident's gown, finished dressing her, and transferred her to the chair before exiting the room. CNA #3 stated that she did not report the incident to the nurse, Director of Nursing (DON), or Administrator until 03/17/25 because she feared retaliation from other staff.

She confirmed she had previously received training and in-services regarding abuse, neglect, and the requirement to report such incidents.

On 04/02/25 at 11:15 AM, during an interview with CNA #2, she stated she was in Resident #2's room providing care to the roommate when she overheard CNA #1 say to Resident #2, If you (expletive) in the bed like you did yesterday, I'm going to beat your (expletive). CNA #2 stated she immediately told CNA #1 that

she could not speak to a resident in that manner, to which CNA #1 replied, I bet it works. CNA #2 explained

she did not report the incident at the time because she was afraid of retaliation from staff, stating that people had recently been losing their jobs and there were concerns about false allegations being made through the compliance hotline. CNA #2 confirmed she had received prior training and in-service education on abuse, neglect, and reporting requirements.

On 04/02/25 at 11:30 AM, during an interview with CNA #4, she stated that she occasionally worked on the same hall as CNA #1 and observed CNA #1 speaking to residents in an aggressive and assertive manner. CNA #4 expressed concern about the tone and way CNA #1 communicated with residents but stated she was told by other staff members that that's just her personality and not to take it seriously. CNA #4 explained that, based on those comments, she did not report the behavior to the Director of Nursing (DON), believing it was not considered a serious issue by other staff.

On 04/02/25 at 11:45 AM, during an interview with CNA #5, he stated that he worked alongside CNA #1 on

the same hall and often heard her speak to residents in an angry tone of voice. CNA #5 stated he initially believed it was just part of her personality and admitted he did not pay much attention to her behavior at the time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 17 255261 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255261 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oaks Rehabilitation and Healthcare Center 3716 Highway 39 North Meridian, MS 39301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 On 04/02/25 at 12:01 PM, during an interview with CNA #1, she denied physically abusing Resident #1 and verbally abusing Resident #2. CNA #1 stated she believed the accusations were fabricated by another CNA Level of Harm - Immediate because she was not part of the clique among staff at the facility. She further stated she had never worked jeopardy to resident health or with CNA #3 on the hall and that CNA #3's primary responsibility was providing showers. CNA #1 confirmed safety she had received training and in-service education on abuse, neglect, and reporting requirements.

Residents Affected - Few On 04/02/25 at 12:05 PM, during an interview with LPN #1, she stated she was the nurse assigned to the hall on 03/07/25. LPN #1 explained that CNA #1 approached her that morning and reported that Resident #1 was combative and refusing care. In response, LPN #1 asked CNA #3 to assist CNA #1 with providing care to the resident. LPN #1 stated she was not made aware of any physical abuse involving the resident and that neither CNA reported any concerns to her. She recalled observing Resident #1 later that shift, seated in a wheelchair, fully dressed, and noted that the resident appeared confused.

On 04/02/25 at 1:00 PM, during an interview with the Social Worker, she stated she was not made aware of

the allegations of physical and verbal abuse until she was informed by the Administrator on 3/17/25. She reported that after learning of the incident, she checked on the involved residents to assess for any concerns and confirmed that no psychosocial issues were identified at that time.

On 04/02/25 at 1:30 PM, during an interview with the Assistant Director of Nursing (ADON) explained that

she had been informed by the DON and the Administrator that two (2) anonymous letters were found on the Administrator's desk alleging that CNA #1 had physically abused Resident #1 and verbally abused Resident #2. The ADON reported that she assisted the DON and the Administrator in conducting full body audits on

the residents and participating in the investigation of the abuse allegations. She confirmed that no bruises or physical injuries were observed on either resident.

On 04/02/25 at 1:45 PM, during an interview with the Administrator, he stated that on 03/17/25, he found two anonymous letters on his desk alleging abuse by CNA #1. The first letter described an incident in which CNA #1 physically abused Resident #1 during incontinent care by grabbing the resident's nose-causing it to bleed-and saying, It's how you deal with crazy (expletive) like you. The second letter alleged that CNA #1 verbally abused Resident #2 by stating, If you (expletive) out the bed like you did yesterday, I'm going to beat your (expletive), while CNA #1 was providing care. The Administrator stated CNA #1 was immediately suspended pending an investigation and was terminated on 03/18/25. As part of the investigation, full body audits were conducted for all residents on the 200 hall where CNA #1 had worked, and cognitive residents were interviewed regarding potential abuse. The Administrator reported that an in-service on abuse and neglect was provided to staff, and a Quality Assurance (QA) meeting was held on 03/26/25. He confirmed

the abuse allegations were substantiated based on the statements from two CNAs: CNA #3, who witnessed physical abuse of Resident #1, and CNA #2, who witnessed verbal abuse directed at Resident #2.

On 04/03/25 at 12:10 PM, during an interview with LPN #2, she described CNA #1 as having good days and bad days, noting that if CNA #1 arrived smiling, it was typically a good day, but if she arrived and did not speak to others, it was a bad day. LPN #2 also stated CNA #1 did not follow instructions well and often argued when asked to perform tasks. She acknowledged she had not documented or reported these concerns to the Director of Nursing (DON) but stated the tasks generally got done. LPN #2 reported she was unaware of any allegations of physical or verbal abuse involving CNA #1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 17 255261 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255261 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oaks Rehabilitation and Healthcare Center 3716 Highway 39 North Meridian, MS 39301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 On 04/03/25 at 12:45 PM, during an interview with Registered Nurse (RN) #1, she stated she was the Unit Manager and had observed that CNA #1 often demonstrated a negative attitude. She further stated CNA #1 Level of Harm - Immediate had shown increased frustration, particularly when the staff schedule was modified or when she was asked jeopardy to resident health or to complete specific tasks. safety

On 04/03/25 at 1:00 PM, during an interview with the Director of Nursing (DON), she stated she was Residents Affected - Few informed about the anonymous letters that had been placed on the Administrator's desk. She reported that CNA #1 was immediately suspended following the allegations. The DON stated that body audits were conducted on all cognitively impaired residents on Station 2, and interviews were completed with cognitively intact residents to assess for any physical or verbal abuse. Staff members working on Station 2 were also interviewed. The DON confirmed that the CNAs failed to report the allegations of abuse until 03/17/25, despite having received in-service training on abuse and neglect at the time of hire.

The Facility presented the following Removal Plan on 4/4/25:

On 4/2/25 Quality Assurance (QAPI) Committee met at 5:45 pm to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees were the Executive Director, (ED), Minimum Data Service (MDS) nurse, Medical Records (MRC), Regional Director of Clinical Services, (RDCS), Assistant Director of Nursing (ADON), Medical Director, Social Services (SSD) Staff Development/ Infection Preventionist nurse, Activities Director (AD), Human Resources (HR) Housekeeping, Dietary Manager, Therapy director, Unit Managers and the Admission Coordinator. There were no changes made to the policy and procedure. The areas that were discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime.

On 3/17/25 body audits were completed on Resident # 1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse was identified.

On 3/17/25 interviews were conducted by SSD with alert and oriented residents on side 2. No residents voiced complaints of abuse.

On 3/17/25 the physician and the Resident Representatives of Resident # 1 and Resident 2 were notified.

On 3/17/25 education was started by the Staff Development Nurse.

On 3/26/25 the Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse.

On 4/2/25 Social Services completed a psychosocial follow up with Resident # 1 and Resident #2.

On 4/2/25 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 17 255261 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255261 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oaks Rehabilitation and Healthcare Center 3716 Highway 39 North Meridian, MS 39301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 On 4/2/25 the ED was educated on the abuse policy by the RDCS and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy. Level of Harm - Immediate jeopardy to resident health or On 4/2/25 the SSD and the Admissions Coordinator interviewed all alert and oriented residents (census) safety using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse. Residents Affected - Few

The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements on 4/2/25 and 100 % has been completed on 4/3/25.

All facility staff members were interviewed by the ED, HR, and ADON by phone on 4/2/25 to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime.

CNA # 2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.

New hires will be educated during orientation.

Corrective Actions were completed on 4/3/25, and the Immediate Jeopardy was removed.

Validation:

The SA validated on 4/4/25, through interview and record review, that all corrective actions had been completed as of 4/3/25, and the IJ removed on 4/4/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 17 255261 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255261 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oaks Rehabilitation and Healthcare Center 3716 Highway 39 North Meridian, MS 39301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Immediate 37415 jeopardy to resident health or safety Based on interviews, record review, and facility policy review, the facility failed to implement its abuse policy, allowing an abusive act to occur without staff intervening or prompt reporting for two (2) of four (4) sampled Residents Affected - Few residents.

Resident #1 was physically abused on 3/7/25 by Certified Nurse Aide (CNA) #1 which was witnessed by CNA #3 and Resident #2 was verbally abused by CNA #1 and was witnessed by CNA #2. CNA #1 and CNA #2 did not intervene to prevent the violation of the residents' rights to be free from abuse.

The facility's failure to intervene and immediately report to the Administrator placed Resident #1, Resident #2 and other residents at risk for similar abuse including the risk for serious harm, injury, impairment, or death.

The situation was determined to Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began

on 3/7/25 when CNA #1 was witnessed physically abusing Resident #1.

The State Agency (SA) notified the facility's Administrator of the IJ and SQC on 4/3/25 at 5:00 PM and the facility provided an acceptable Removal Plan on 4/3/25 and the IJ was removed on 4/4/25.

The SA validated the Removal Plan on 4/4/25 and determined the IJ was removed on 4/4/25, prior to exit. Therefore, the scope and severity for 42 CFR(s): 483.12(b)(1) Implement Written Policies (

F-Tag F607

Harm Level: Immediate A record review of the Admission Record revealed the facility admitted Resident #2 on 10/3/2019 with

Residents Affected: Few which indicated her cognition was severely impaired. Section GG revealed Resident #2 is dependent on staff

F-F607) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.

Findings Include:

A review of the facility's, Abuse, Neglect, Exploitation & (and) Misappropriation revised 11/16/22, revealed, . Procedure .2. Training .Employee obligation All employees have a duty to respect the rights of all residents . and to prevent others from violating their rights. Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, .to a resident, is obligated to report such information, but no later than 2 hours after the allegation is made .to the Administrator and to other officials in accordance with State Law. An employee shall be deemed to have violated his obligations .if he does any of the following .Fails to report an incident of abuse witnessed by or known to him/her .

Resident #1

A record review of the Admission Record revealed the facility admitted Resident #1 on 3/08/2013 with current diagnoses including Parkinson's Disease and Dementia.

A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated her cognition was moderately impaired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 17 255261 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255261 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oaks Rehabilitation and Healthcare Center 3716 Highway 39 North Meridian, MS 39301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Resident #2

Level of Harm - Immediate A record review of the Admission Record revealed the facility admitted Resident #2 on 10/3/2019 with jeopardy to resident health or current diagnoses including Hypertension and Major Depressive Disorder. safety

A record review of the Quarterly MDS with an ARD of 3/12/25 revealed Resident #2 had a BIMS score of 3 Residents Affected - Few which indicated her cognition was severely impaired. Section GG revealed Resident #2 is dependent on staff for toileting hygiene.

In an interview on 4//2/25 at 11:00 AM with CNA # 3, she stated that on 3/07/25 at approximately 6:20 AM,

she was working the overnight shift (11:00 PM - 7:00 AM) and Licensed Practical Nurse (LPN) #1 asked her to assist CNA #1 with providing care to Resident #1 because she was reportedly combative. As care began, Resident #1 swung at both CNAs. The resident grabbed CNA #1 by the hair and in response, CNA #1 grabbed the resident's nose and twisted it upwards, which caused the resident's nose to bleed. According to CNA #3, CNA #1 then stated, This is how you deal with crazy (expletive) like you. CNA #3 recalled telling CNA #1, You can't treat and talk to her like that, and stated she attempted to leave the room to locate the nurse but did not see her nearby. Not wanting to leave the resident alone with CNA #1, CNA #3 returned to

the room and offered to finish providing care. She stated that CNA #1 appeared to ignore her and refused to leave the room. CNA #1 continued providing care, cleaned the blood from the resident's face using the resident's gown, finished dressing her, and transferred her to the chair before exiting the room. CNA #3 admitted that she did not report the incident to the nurse, Director of Nursing (DON), or Administrator until 03/17/25, leaving all residents at risk for potential abuse from CNA #1. CNA #3 revealed she was aware that

she should have intervened and reported the abuse immediately because she had been trained on the facility's abuse policy, but she feared retaliation from other staff.

In an interview with CNA #2 on 4/02/25 at 11:15 AM, she stated she was in Resident #2's room providing care to the roommate when she overheard CNA #1 say to Resident #2, If you (expletive) in the bed like you did yesterday, I'm going to beat your (expletive). CNA #2 stated she immediately told CNA #1 that she could not speak to a resident in that manner, to which CNA #1 replied, I bet it works. CNA #2 explained she did not report the incident at the time because she was afraid of retaliation from staff, stating that people had recently been losing their jobs and there were concerns about false allegations being made through the compliance hotline. CNA #2 also revealed that she had been trained on the facility's abuse policy which instructed staff to report abuse to protect the residents.

During an interview with CNA #1 on 4/02/25 at 12:01 PM, she denied physically abusing Resident #1 and verbally abusing Resident #2. CNA #1 stated she believed the accusations were fabricated by another CNA because she was not part of the clique among staff at the facility. She further stated she had never worked with CNA #3 on the hall and that CNA #3's primary responsibility was providing showers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 17 255261 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255261 B. Wing 04/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Oaks Rehabilitation and Healthcare Center 3716 Highway 39 North Meridian, MS 39301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 During an interview with the Administrator on 4/02/25 at 1:45 PM, he stated that on 3/17/25, he found two anonymous letters on his desk alleging abuse by CNA #1. The first letter described an incident in which CNA Level of Harm - Immediate #1 physically abused Resident #1 during incontinent care by grabbing the resident's nose, causing it to jeopardy to resident health or bleed, and saying, It's how you deal with crazy (expletive) like you. The second letter alleged that CNA #1 safety verbally abused Resident #2 by stating, If you (expletive) out the bed like you did yesterday, I'm going to beat your (expletive), while CNA #1 was providing care. The Administrator stated CNA #1 was immediately Residents Affected - Few suspended pending an investigation and was terminated on 03/18/25. The Administrator also confirmed that CNAs #2 and #3 did not receive disciplinary action regarding their inaction of immediately protecting the residents and reporting, however, they were inserviced on the abuse policy.