Every finding on record at Cornerstone Rehabilitation and Healthcare Center

Based on observation, record review, interview and facility policy review, the facility failed to store and serve foods in a sanitary manner and maintain a clean dietary department for two (2) of four (4) days of survey. Findings include:Record review of facility policy titled, Environment, dated 06/2025, stated, All food preparation areas, food services, and dining areas will be maintained in a clean and sanitary condition. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.Record review of policy titled, Food Storage: Cold Foods, dated 02/2026, stated, Freezer temperatures will be maintained as a temperature of 0 degrees or below.Observation on 04/06/2026 at 6:20 PM revealed on initial tour of the dietary department that a large amount of food debris and spilled liquids was observed on the floors throughout the dietary department. Along with discarded silverware, discarded pieces of paper, packs of butter, packs of jelly, dried pieces of pasta, shredded cheese and lettuce were observed on the floors in the dietary department. The floor in the dietary department was extremely sticky and the whole area was very unkept. During this observation on 04/06/26, it was noted that a large amount of grease and food build up was on the glass of the steam table backsplash. Observation revealed a gallon size plastic bag dated 02/24/26 with around 20 breadsticks, on a cart beside a blender. Observation revealed Freezer 2 had a temperature of 48 degrees Fahrenheit (F) with thawed biscuits, rolls, and breaded chicken strips inside the freezer that were mushy to the touch and not frozen. A clean dish rack in the dish room was observed to have dirty gloves laying on the dish rack with the clean dishes, discarded salt and pepper packets and a large amount of food debris on the bottom rack of the clean dish rack.Interview on 04/06/26 at 6:25 PM with Dietary Employee #1 confirmed that she had been there since early that morning and that usually they try to clean up after each meal, but they have not cleaned the dietary area today. Interview and observation with the Dietary Manager (DM) on 04/06/26 at 6:38 PM confirmed that the breadsticks should have been discarded and that they were over a month old. The DM confirmed the temperature in the freezer was 48 degrees F and she stated, We had a freezer break down about a week ago and we moved the items to this freezer (Freezer 2), but I thought it was working. The DM confirmed that the dietary department was unkempt and needed to be cleaned and swept. She confirmed the large amount of food debris on the floor, the floor having large amounts of grease build up and sticky and agreed that the dietary department needed to be cleaned. DM confirmed that this rack should be clean and the dirty gloves and food debris should not be on the clean dish rack.Observation of the food tray line and interview with the DM on 04/08/26 at 12:15 PM it was observed during food tray line assembly that Dietary Employee #2 had soiled gloves on and touched the dinner rolls with the soiled gloves when assembling the lunch trays. The DM confirmed that dietary employees should not touch food with dirty gloves.

Based on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. (4th Quarter 2025 July 1-September 30). Findings include:Review of the facility policy titled Reporting Direct-Care Staffing Information (Payroll-Based Journal), with a review date of 4/2026, revealed, Policy Statement: Staffing and census information will be reported electronically to Centers for Medicare and Medicaid Services (CMS) through the PBJ system in compliance with Section 6106 of the Affordable Care Act .Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 4 2025 (July 1-September 30), revealed the facility triggered on this report for excessively low weekend staffing.During an interview on 4/8/2026 at 2:12 PM, the Administrator and PBJ Coordinator (via telephone) confirmed the facility included Director of Nursing (DON) hours, Registered Nurse (RN) with administrative duties hours, and Licensed Practical Nurse (LPN) with administrative duties hours in PBJ reporting, even when those staff did not provide direct resident care. She stated, We are within CMS guidelines to claim those hours, and it helps our 5-star rating to do so. The Administrator confirmed that entering those hours incorrectly would show an increased number of staff throughout the week and the staffing numbers would fall on the weekends.

Based on observation, staff interview, and facility policy review, the facility failed to ensure medications were properly labeled and stored in accordance with accepted standards of practice for two (2) of three (3) medication carts observed. Specifically, the facility failed to ensure multi-dose vials were dated upon opening and discarded within the required timeframe. (Residents #4, # 7, #36, #40, #69, and #90)Findings include:Review of the facility policy titled Medication Labeling and Storage, with a review date of February 2023, revealed, .Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days.During an observation of A-Hall medication cart #1 on 4/8/2026 at 2:47 PM with Licensed Practical Nurse (LPN) #2, Resident #4's opened multi-dose vial of Olopatadine HCl Ophthalmic Solution 0.1% had an open date of 2/27/2026; Resident #7's opened multi-dose vial of Latanoprost Ophthalmic Solution 0.005% had an open date of 2/26/2026; Resident #36's multi-dose vial of Lantus Subcutaneous Solution 100 unit/milliliter was observed opened without an open date, and Resident #36's opened multi-dose vial of Artificial Tears Ophthalmic Solution 1.4% had an open date of 2/1/2026; Resident #40's opened multi-dose vial of Timolol Maleate Solution 0.5% had no open date; and Resident #69's opened multi-dose vial of Artificial Tears Ophthalmic Solution had an open date of 2/15/2026. LPN #2 stated, I think insulin is good for 30 days. She further stated insulin could lose effectiveness over time and referenced pharmacy guidelines. Additionally, she stated other multi-dose vials were good for 30 days after opening.During an observation of B-Hall medication cart #2 on 4/8/2026 at 3:03 PM with LPN #4, Resident #90's opened multi-dose vial of Latanoprost Ophthalmic Solution 0.005% was observed without an open date.During an interview on 4/8/2026 at 3:11 PM, the Assistant Director of Nursing (ADON) confirmed all multi-dose vials should have an open date. She stated insulin is only good for 28 days after opening and that other multi-dose medications, such as eye drops, are typically good for 30 days after opening.Record review of the admission Record indicated that the facility admitted Resident #4 on 12/19/2025 with a medical diagnosis that included Heart Failure. Record review of Resident #4's Order Summary Report dated 4/9/26, revealed an active order for Olopatadine HCl Ophthalmic Solution 0.1% with order date 12/19/2025.Record review of the admission Record indicated that the facility admitted Resident #7 on 7/20/2009 with a medical diagnosis that included Alzheimer's Disease with late onset. Record review of Resident #7 's Order Summary Report dated 4/9/26, revealed an active order for Latanoprost Ophthalmic Solution 0.005% with order date 8/13/2024.Record review of the admission Record indicated that the facility admitted Resident #36 on 5/28/2021 with a medical diagnosis that included Type 2 Diabetes Mellitus without complications. Record review of Resident #36's Order Summary Report dated 4/9/26, revealed an active order for Lantus Subcutaneous Solution 100 unit/milliliter with order date 9/10/2025 and Artificial Tears Ophthalmic Solution 1.4% with order date 7/26/2024.Record review of the admission Record indicated that the facility admitted Resident #40 on 11/5/2021 with a medical diagnosis that included Unspecified Protein-Calorie Malnutrition. Record review of Resident #40's Order Summary Report dated 4/9/26, revealed an active order for Timolol Maleate Solution 0.5% with order date 11/21/2021.Record review of the admission Record indicated that the facility admitted Resident #69 on 1/29/2024 with a medical diagnosis that included Huntington's Disease. Record review of Resident #69's Order Summary Report dated 4/9/26, revealed an active order for Artificial Tears Ophthalmic Solution with order date 2/10/2026.Record review of the admission Record indicated that the facility admitted Resident #90 on 4/7/2026 with a medical diagnosis that included Traumatic Subdural Hemorrhage with loss of consciousness of unspecified duration, subsequent encounter. Record review of Resident #90's Order Summary Report dated 4/9/26, revealed an active order for Latanoprost Ophthalmic Solution 0.005% with order date 4/7/2026.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure proper perineal care practices to prevent the spread of bacteria for one (1) of two (2) residents observed for perineal care. Resident #45 Findings Include:Review of the facility policy titled Perineal Care revised 4/16/24, revealed under, Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. During an observation of perineal care for Resident #45 on 4/8/26 at 11:15 AM, Certified Nurse Aide (CNA) #2 performed care and, after cleansing the front perineal area, turned the resident onto her side, resident had a bowel movement. CNA 2 then re-dipped previously used washcloths into the water basin after she had used that water to clean the bowel movement and then used the same water to cleanse the back perineal area. The aide stated prior to exiting the room that she realized the practice was incorrect. On 4/8/26 at 11:40 AM, an interview with CNA #2 confirmed she reused washcloths while providing care to Resident #45 because she was out of clean supplies. She confirmed she should have stopped to retrieve extra supplies and that providing improper perineal care increased the resident's risk for spread of bacteria and urinary tract infection. An interview with the Director of Nursing on 4/9/26 at 2:41 PM revealed the aide should have obtained additional clean washcloths to prevent the spread of germs during perineal care. Record review of the admission Record revealed the facility admitted Resident #45 on 1/24/23 with medical diagnoses that included Epilepsy and Need for Assistance with Personal Care. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 11, which indicated Resident #45 was moderately cognitively impaired. Further review revealed under section H, the resident was always incontinent of bowel and bladder.

Based on record review and staff interview, the facility failed to ensure residents or their representatives were provided with required Beneficiary Notices, including Skilled Nursing Facility Advanced Beneficiary Notices (ABNs) for one (1) of three (3) residents reviewed for Beneficiary Protection Notifications. Residents #4 Findings include:Review of a statement on facility letterhead dated 4/7/26 and signed by the Administrator revealed the facility did not have a policy specific to Beneficiary Notices, including Advanced Beneficiary Notices (ABNs).Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form revealed that one of the three residents reviewed remained in the facility; however, Resident #4 was not provided with a Skilled Nursing Facility Advanced Beneficiary Notice (ABN).During an interview on 4/7/2026 at 10:36 AM, the Business Office Manager confirmed she did not provide the SNF ABN to the resident or the resident's responsible party. She stated, I didn't realize that I needed to complete the ABN form. I thought the Notice of Medicare Non-Coverage (NOMNC) was enough and that it covered all of that.During an interview on 4/7/2026 at 11:41 AM, the Administrator confirmed he had the same understanding as the Business Office Manager and believed the Notice of Medicare Non-Coverage (NOMNC) was the only notice required to be provided to the resident or responsible party.Review of the admission Record indicated that the facility admitted Resident #4 on 12/19/2025 with a medical diagnosis that included Heart Failure.

Based on staff interviews, record review, and facility policy review, the facility failed to accurately complete Section O of the Minimum Data Set (MDS) quarterly assessment during the 7-day observation look-back period for one (1) of four (4) residents reviewed for dialysis services. Resident #16Findings Include:Review of the facility policy titled MDS Coding Policy dated 8/11/20 revealed, Proper Name affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately .Record review of the Order Summary Report revealed that Resident #16 has an order to receive dialysis three (3) days a week, on Tuesday, Thursday, and Saturday, at the proper name of dialysis center, with a start date of 7/14/25.Record review of Resident #16's Quarterly MDS with an Assessment Reference Date (ARD) of 1/6/26 revealed under section O that Resident #16 was not coded for receiving dialysis.Record review of Resident #16's Quarterly MDS with an ARD of 4/1/26 revealed under section O that Resident #16 was not coded for receiving dialysis.During an interview on 4/08/26 at 8:30 AM, the MDS Nurse confirmed that Resident #16 receives dialysis services three times weekly. She revealed that, for the past two quarterly MDS assessments, Resident #16 was not coded as receiving dialysis treatments in Section O. The MDS Nurse stated she was instructed not to code dialysis during the seven-day look-back period if all three communication sheets from the dialysis center were unavailable. The MDS Nurse further confirmed that despite the missing documentation, Resident #16 attended and received dialysis treatments on all scheduled days during the look-back period.In an interview on 4/9/2026 at 10:25 AM, the Administrator (ADM) revealed if Resident #16 is receiving dialysis services, then his MDS should accurately reflect that. Record review of Resident #16's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease and Dependence on Renal Dialysis. Record review of Resident #16's MDS with ARD of 4/1/26 indicated a Brief Interview for Mental Status (BIMS) of 11, which indicated the resident has moderate cognitive impairment.

Based on record review, observation, staff interviews, and facility policy review, the facility failed to develop and implement a person-centered comprehensive care plan for three (3) of 38 residents reviewed (Resident #10, #40, and #73). Findings Include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered reviewed 1/2023, revealed under, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #10 On 4/06/26 at 6:32 PM, and again on 4/07/2026 at 3:38 PM an observation of Resident #10 revealed the resident lying in bed with his hair oily, matted, and tangled. Resident #10 had a foul odor, and his room had a foul odor. On 4/08/26 at 9:25 AM an observation and interview with Certified Nursing Assistant (CNA) #2 confirmed Resident #10's hair was unclean and he had an odor. She stated that she was not on shift the previous day when he had his last shower, and it's necessary for an aide to assist him with soap and shampoo because he will just stand in the shower and let the water splash him, he does not have awareness to bath his body and shampoo his hair. On 4/08/26 at 11:35 AM an observation and interview with the Administrator confirmed Resident #10' s hair had not been washed and was unclean. He stated it is the expectation of the facility for the staff to assist resident in showering and shampooing their hair if resident is unable to. During an interview on 4/08/26 at 3:00 PM with the Minimum Data Set (MDS) Nurse, she confirmed that Resident #10's care plan was not implemented for assistance with showering because she had him marked as independent. Record review of the admission Record revealed the facility admitted Resident #10 on 7/02/2025 with medical diagnoses that included Alzheimer's Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/2026 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 1, which indicated Resident #10 was severely cognitively impaired. Resident #40 Record review of Resident #40's Care Plan Report revealed under, Focus: I have an ADL (activity of daily living) self-care performance deficit r/t (related to) weakness, dementia. Also revealed under, Interventions/Tasks: Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated. On 4/6/26 at 7:29 PM and again on 4/7/2026 at 8:18 AM an observation of Resident #40 revealed the resident lying in bed with her hair uncombed, matted, and tangled. The scalp had visible yellowish, dry, flaky buildup to the entire front scalp area, consistent with lack of washing. On 4/8/26 at 8:04 AM, an observation and interview with Licensed Practical Nurse (LPN) #2 confirmed Resident #40 had unclean hair with visible residue and buildup. During an interview on 4/8/26 at 11:20 AM, the MDS Nurse revealed that she is responsible for developing residents' comprehensive care plans and that care plans are driven by the MDS assessment. She stated the purpose of the care plan is to inform staff on how to care for residents based on their individual needs. Record review of the admission Record revealed the facility admitted Resident #40 on 11/5/21 with medical diagnoses that included Unspecified Dementia, Muscle Weakness, and Need for Assistance with Personal Care. Record review of the MDS with an ARD of 2/12/26 revealed under section C, a BIMS summary score of 3, which indicated Resident #40 was severely cognitively impaired. Resident #73 Record review of Resident #73's Care Plan Report revealed no care plan was in place for smoking. Record review of the MDS with ARD of 8/25/25 indicated under Section J that Resident #73 currently uses tobacco. During an interview on 4/7/2026 at 10:44 AM, Resident #73 revealed he is a smoker. During an interview on 4/8/26 at 11:20 AM, the MDS Nurse revealed that she is responsible for developing residents' comprehensive care plans and that care plans are driven by the MDS assessment. She stated the purpose of the care plan is to inform staff on how to care for residents based on their individual needs. The MDS Coordinator further revealed that if a resident smokes, a smoking care plan should be developed to address those needs. She confirmed that, according to the Annual Comprehensive MDS assessment dated [DATE], the resident was coded as a current tobacco user. She acknowledged that a smoking care plan had not been developed for the resident and stated the omission occurred in error. Record review of Resident #73's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Chronic Systolic Congestive Heart Failure, and Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of Resident #73's MDS with an ARD of 4/1/26 indicated a BIMS score of 13, which indicated the resident is cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents who were dependent on staff for hair care and shampooing received the necessary hygiene services to maintain personal cleanliness and grooming for two (2) of eight (8) residents reviewed for activities of daily living (ADL) care during the initial pool. Resident #10 and #40Findings Include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting revised 3/18, revealed under, Policy Statement: .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Resident 10 An observation of Resident #10 on 4/06/26 at 6:32 PM, and again on 4/07/2026 at 3:38 PM revealed the resident lying in bed with his hair oily, matted, and tangled. Resident #10 had a foul odor, and his room had a foul odor. An observation and interview with Certified Nursing Assistant (CNA) #2 on 4/08/26 at 9:25 AM confirmed Resident #10's hair was unclean and he had an odor. She stated that she was not on shift the previous day when he had his last shower, and it's necessary for an aide to assist him with soap and shampoo because he will just stand in the shower and let the water splash him. An observation and interview with the Administrator on 4/08/26 at 11:35 AM confirmed Resident #10' s hair had not been washed and was unclean. He stated it is the expectation of the facility for the staff to assist residents in showering and shampooing their hair if resident is unable to. Record review of the admission Record revealed the facility admitted Resident #10 on 7/02/2025 with medical diagnoses that included Alzheimer's Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/2026 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 1, which indicated Resident #10 was severely cognitively impaired. Resident #40 An observation of Resident #40 on 4/6/26 at 7:29 PM and again on 4/7/2026 at 8:18 AM revealed the resident lying in bed with her hair uncombed, matted, and tangled. The scalp had visible yellowish, dry, flaky buildup to the entire front scalp area, consistent with lack of washing. An observation and interview with Licensed Practical Nurse (LPN) #2 on 4/8/26 at 8:04 AM confirmed Resident #40 had visible hair residue and buildup. She revealed the resident's scheduled bath days were Monday, Wednesday, and Friday and stated that hair shampooing was considered part of bathing and should be completed on those days by the aide to ensure cleanliness. An observation and interview with the Administrator on 4/8/26 at 8:14 AM confirmed Resident #40's hair had not been washed and was unclean. He stated his expectation was for the resident to be clean and that her hair should be washed with bathing on scheduled bath days. Record review of the admission Record revealed the facility admitted Resident #40 on 11/5/21 with medical diagnoses that included Unspecified Dementia, Muscle Weakness, and Need for Assistance with Personal Care. Record review of the MDS with an ARD of 2/12/26 revealed under section C, a BIMS summary score of 3, which indicated Resident #40 was severely cognitively impaired.

Based on staff and resident interview, observations, record review, and facility policy review, the facility failed to ensure each resident was treated with dignity and respect for three (3) of ten (10) residents sampled. Resident #2, #4, and #5. Findings Include:Record review of the facility policy titled, Statement of Resident Rights undated, revealed, If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the Facility Administrator . You have a right to: 4.be treated with courtesy, consideration, and respect.Resident #2An interview with Resident #2 Spouse/Resident Representative (RR) on 9/11/25 at 10:00 AM, revealed that she has some issues with Certified Nurse Aide (CNA) #1, she revealed she's rude and very snappy. She stated, My husband is here for therapy, and he deserves to be treated with kindness and respect like everyone else in this place. She stated that her daughter told her that she needed to report it, but she confirmed that she hasn't because I don't want anything to be taken out on my husband. The RR stated, Because if that happens, then they will see the bad side of me. The RR stated, I feel sorry for the patients who may not have a family member to stand up for them. The least that she (CNA #1) could do is be kind.Record review of the admission Record revealed the facility admitted Resident #2 on 8/21/25 with medical diagnoses, which include Cerebral Infarction and Hemiplegia and Hemiparesis.Record review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident is cognitively intact.Resident #4An interview with Resident #4 on 9/11/25 at 10:25 AM, the resident stated, Everyone is nice here except one, and she's here working today. Resident #4 identified CNA #1 as the person that she is referring to and revealed, the lady from the therapy department came to see if I was ready for therapy the other day and I told her I'm waiting for my aide to come and get me ready. I put my call light on, and she (CNA #1) came in, and I told her I needed to get ready for therapy. I couldn't understand what she was saying because she was mumbling, but then she said Well, get your clothes ready, and she just walked out the door. Resident #4 stated, I can't get up and get my clothes ready; if I could, I wouldn't be here. She revealed she seldom does anything for me; she'll answer the call light, make a remark, and then leave, and someone else will have to come in to help me. She revealed I don't know why she acts that way to people, it may just be her personality, or maybe she's just not nice to anyone. She revealed she's not fearful of the aide, but stated that she is just not a nice person.The admission Record review revealed that the facility admitted Resident #4 on 4/7/21 with medical diagnoses, including Lack of Coordination and Need for assistance with personal care.Record review of Resident #4's MDS with an ARD of 7/30/25 revealed a BIMS score of 14, which indicated the resident is cognitively intact. Resident #5During an interview on 9/11/25 at 10:30 AM, Resident #5 stated, Most of the employees here are nice, but there is one here today that's not kind. Resident #5 confirmed that she is here for therapy, and then she will go back home and confirmed that she doesn't have much longer to put up with her. Resident #5 confirmed that the aide hasn't done anything abusive to her, but she is just mean-acting, but she isn't going to stir anything up because I'm just waiting to get back home. The admission Record review revealed that the facility admitted Resident #5 on 9/5/25 with medical diagnoses, including Encounter for other Orthopedic Aftercare and Fracture of Unspecified Part of Neck of Left Femur.Record review of Resident #5's MDS revealed a BIMS score of 12 on 9//8/25, which indicated the resident has moderate cognitive impairment.During an interview on 9/11/25 at 11:00 AM, State Agency (SA) observed two staff members sitting at the B-hall nursing unit. One staff member (CNA #2) was sitting at the desk, and another staff member (CNA #1) was sitting with her back to the SA and was observed with a hoodie over her head. SA inquired how many Certified Nurse Aides (CNA) were working on that hallway and CNA #2 stated two. CNA #1 stated one and two and pointed to herself and CNA #2 in a gruff tone. SA asked their names, and CNA #2 gave her first and last names. When the SA asked CNA #1 her name, she answered her first and middle name. SA asked if her middle name was her last name, and CNA stated, No, rudely.During an interview with the Director of Nurses (DON) and the Administrator (ADM) on 9/11/25 at 11:30 AM, the DON revealed that she was aware that the residents had complained about CNA #1 and her mannerisms and behaviors. They both confirmed that they had talked with CNA #1 about her tone with the residents and stated that It's just her personality and demeanor. The Administrator revealed we have both verbally spoken to her about her abrasiveness and tone multiple times. The DON acknowledged that CNA #1 had a Disciplinary Action Record completed on 3/26/25 because a grievance was filed stating the employee talks too fast and the residents cannot understand her and she is very short with residents. The DON and ADM both acknowledged that the residents in the facility have the right to be treated with respect and kindness and further revealed that if they had a loved one in their facility, they would not like someone to take care of them who is rude and short with them.An interview on 9/11/25 at 12:20 PM with an Anonymous Employee #1 revealed she had overheard CNA #1 being rude and not friendly to the residents. The employee confirmed that she tries to reassure the residents and to let them know it's okay and that I have reported it to the nursing supervisor. She revealed that the DON was aware of it too, but she did not know what had happened.An interview on 9/11/25 at 12:30 PM, Registered Nurse (RN) #1 revealed she had overheard the DON and Assistant Director of Nurses (ADON) speaking with CNA #1 about her tone, which can be abrupt. RN #1 revealed she's not abusive, but it's just the way she talks to people and it's not okay.During an interview on 9/11/25 at 2:20 PM, Licensed Practical Nurse (LPN) #1 revealed that it had been reported to her by another staff member that CNA #1 was a little aggressive and rude to the residents. She revealed she reported it to the DON. She revealed she has worked with CNA #1 in the past; she's loud and gruff, but I've never witnessed her abuse anyone. LPN #1 confirmed that each resident has the right to be treated with respect and dignity.In an interview on 9/11/25 at 2:35 PM, Anonymous Employee #2 revealed that there is another staff member who is rude and hateful and she (CNA #3) works night shift on the B-Hall and is hateful and talks loudly to her residents. She revealed that CNA #3 just returned to work after being suspended for cussing in the hallway and being rude to other staff members.During an interview on 9/11/25 at 2:50 PM, Anonymous Employee #3 confirmed she witnessed CNA #3 cursing in the hallway on night and being loud toward a resident and a family member, and stated that it was reported it to the DON.Record review of CNA #3 Disciplinary Action Record dated August 29, 2025, revealed that she was terminated after investigation of cursing in the hallway, threatening to whip staff a**, and being rude to a resident. Record review of a typed letter dated August 29, 2025, and signed by the DON revealed, I received a call this morning from a family member stating that a CNA had been very rude to her and her mother . She said that the CNA had a nasty tone and was just rude. the CNA in question was yelling and cursing in the hallway last night and threating to whoop whoever took her supplies a** Record review of CNA #3 Disciplinary Action Record dated 11/30/24 and 12/1/24, Facts regarding incident: Unsampled resident reported CNA being loud and rude with him at night.In an interview on 9/11/25 at 3:10 PM, the DON acknowledged that there were complaints made to her regarding CNA #3 being rude to a resident, in front of the resident's family, and cursing loudly in the hallway. She confirmed CNA #3 had several previous written Disciplinary Actions for her rudeness. She revealed that we had suspended her and did an investigation for the August 28th occurrence and was informed by their corporate office that they could allow CNA #3 to return to work with a last and final warning and that they are monitoring her closely. During an interview on 9/11/25 at 3:25 PM, the Administrator stated each resident deserves to be treated with dignity and respect and live in a peaceful environment. He stated after listening to these concerns, the facility failed to honor these residents' rights.

Based on record review, staff interview, and facility policy review, the facility failed to accurately submit the Payroll-Based Journal (PBJ) for the 4th quarter (July 1 - September 30) in the fiscal year (FY) 2024. Findings include: A review of the facility policy titled, Reporting Direct-Care Information (Payroll-Based Journal), last reviewed 3/2023, revealed Policy Statement: Staffing and census information will be reported electronically to CMS (Centers for Medicare and Medicaid Services) through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act .2. Direct-care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees .10. Staffing data includes the number of hours worked each day by each staff member . Record review of the PBJ Staffing Data Report revealed that the facility triggered for low weekend staffing for the fourth quarter of 2024. In an interview with the Director of Nursing (DON) and the Administrator on 1/22/25 at 3:12 PM, they revealed during the timeframe the facility triggered for low weekend staffing, the facility was having to use a lot of agency nursing staff. The DON and the Administrator both confirmed that some agency staff hours were not accurately submitted to the PBJ, resulting in the low weekend staffing being triggered.

Based on observation, staff, resident, and resident representative interview, record review and facility policy review the facility failed to provide personal hygiene for five (5) of 21 sampled residents. Resident #15, Resident #31, Resident #55, Resident #67, and Resident #71. Findings Include Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, revealed, Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain grooming and hygiene needs Resident #15 An observation and interview on 01/21/25 at 10:30 AM, revealed Resident #15 sitting up on the side of her bed with facial hairs scatted over her chin and upper lip that was approximately one-half inch long. She stated that she use to be able to use tweezers when she was at home and kept her facial hair plucked. She revealed that her hair needed to be removed but she didn't have a way to do it, and no one had offered to shave or remove her facial hair since she had been there. She stated that she knew they get busy and probably forget about her but she didn't like to have hair on her face. An observation and interview on 01/22/25 at 10:30 AM with Certified Nursing Assistant (CNA) #3, revealed that facial hair was supposed to be addressed during a resident's bath or shower time and as needed and confirmed that Resident #15 had scattered facial hair on her chin and upper lip. She admitted that most ladies do not want facial hair, and it should be removed unless they refuse. An interview on 01/22/25 at 10:38 AM with Registered Nurse (RN) Supervisor #1, confirmed the facial hair on Resident #15's chin and upper lip. She revealed that most ladies were concerned about their appearance and would want it removed. She confirmed that facial hair should be addressed and removed during the resident's bath or shower and as needed. Record review of Resident #15's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Other Fracture of Right Lower Leg, Unspecified Fall, and Chronic Obstructive Pulmonary Disease. Record review of Resident #15's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/24 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 11 which indicated that she had moderate cognitive deficits. Resident #71 An observation and interview with Resident #71 on 01/21/25 at 10:00 AM revealed him lying in bed with long, jagged fingernails on his bilateral hands and was approximately one-half to three-fourths long. Resident #71 stated that his fingernails were too long, and they had started to split and crack. He revealed that no one had offered to trim his fingernails since he came there and stated, I need them cut. An observation and interview with Resident #71 on 01/22/25 at 9:38 AM, revealed no change in the appearance of the resident's fingernails. He stated that he used to be able to take care of his own nails when he was home, but not anymore and he liked to keep his nails a lot shorter than they are now. An observation and interview on 01/22/25 at 10:24 AM with CNA #3, revealed that nail care was part of personal hygiene and should be looked at and taken care of every day and as needed. CNA #3 revealed that Resident #71's fingernails appeared like they had not been clipped in a while. An observation and interview with RN Supervisor #1 on 1/22/25 at 10:34 AM confirmed Resident #71's nails needed to be trimmed and stated that long jagged fingernails could cause scratches, skin tears and possible spread of infection. An interview with Director of Nursing (DON) on 01/22/25 at 10:50 AM revealed that fingernails should be cleaned every day and facial hair should be addressed with the resident's bath or as needed. Record review of Resident #71's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Unspecified Dementia, Parkinson's Disease, and Need for Assistance with Personal Care. Record review of Resident #71's MDS with an ARD of 12/16/24 under Section C revealed a BIMS score of 11 which indicated that he had moderate cognitive deficits. 46013 Resident #31 An observation and interview on 1/21/25 at 10:05 AM revealed Resident #31's bilateral fingernails were approximately one and one-half (1 1/2) inches long and jagged past the tip of fingers; a brown substance was under each nail. Resident #31 revealed they need to be cut; they are too long. Facial hair was approximately one inch long and was noted on the cheeks, chin, and above the resident's lip. Resident #31 stated, I've been trying to get shaved, and I want it all shaved off. During a phone interview on 1/21/25 at 2:57 PM, Resident #31's Representative (RR) stated We had visited before and found him to have long fingernails and not be shaved. We have brought it to the staff's attention before. An observation and interview on 1/22/25 at 9:05 AM revealed that Resident #31 was lying in bed with no change in appearance from the prior day. Resident #31 again confirmed that he wants to be shaved, and his nails cut. In an interview and observation on 1/22/25 at 9:15 AM, CNA #1 confirmed Resident #31's nails were very long, and that he needed to be shaved and stated, I'm not sure when his nails or shaving has last been. She revealed the resident had refused to have his nails cut in the past, so she doesn't ask him anymore if he wants them to be done. During an observation and interview on 1/22/25 at 9:25 AM, the DON confirmed Resident #31's fingernails were long and jagged, with a brown substance under them and that he needed shaving. She stated that this is not how we operate. Regardless, if he has refused in the past, he should still be offered to have his nails cleaned and cut and his facial hair shaven, which is part of his daily grooming. A record review of Resident #31's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Hypertensive Heart Disease with Heart Failure and Major Depressive Disorder. Record review of the MDS with an ARD of 11/29/24 revealed Resident #31 had a BIMS score of 06, which indicated the resident had severe cognitive impairment. Resident #55 An observation and interview on 1/21/25 at 10:25 AM revealed Resident #55's bilateral fingernails were approximately one-half (1/2) inch long and jagged past the tip of his fingers. Resident #55 revealed he likes them to be cut shorter and neater. An observation on 1/22/25 at 8:45 AM revealed Resident #55's fingernails remain one-half inch long and jagged past the tip of his fingers. An observation and interview on 1/22/25 at 9:20 AM, CNA #2 revealed she was assigned to Resident #55 today and confirmed that his fingernails on bilateral hands were long and jagged. She revealed his fingernails should be looked at every day when he gets either a bed bath or a shower and that they should be kept trimmed to prevent him from scratching himself and causing a skin tear. A record review of Resident #55's Admission record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Pneumonia, Essential (Primary) Hypertension, and Major Depressive Disorder. Record review of the MDS with an ARD of 11/8/24, revealed Resident #55 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. 47157 Resident #67 An observation of Resident # 67 on 11/21/25 at 9:25 AM, revealed all the resident's fingernails on the right hand to have a dried dark brown substance surrounding the nail cuticles and under the nail beds. An observation on 11/21/25 at 1:45 PM, revealed Resident #67's fingernails to the right hand were still observed to have a dried dark brown substance surrounding the nail cuticles and under the nail beds. In an observation and interview with Licensed Practical Nurse (LPN) #2 on 1/22/25 at 9:40 AM confirmed that Resident # 67's fingernails on the right hand had a dried dark brown substance around the nail cuticles and under the nail beds and it appeared to be feces. She then stated that Resident #67 had not received nail care or hand hygiene lately and confirmed that failing to perform hand hygiene and nail care could lead to infections. In an interview with CNA #4 on 1/22/25 at 9:45 AM, she revealed that Resident #67 was prone to playing in her stool and confirmed she had not made rounds on the resident and seen the condition of her nails this shift. In an interview with the DON on 1/22/25 at 9:49 AM, she confirmed that not performing nail care was an infection control concern. Review of the Admission Record revealed Resident #67 was admitted by the facility on 7/29/24 with a diagnosis of Nontraumatic Subarachnoid Hemorrhage. Record review of Resident #67's MDS with an ARD of 11/5/24 revealed a BIMS score of 99 indicating the resident was unable to complete the interview. Section GG revealed that Resident #67 was dependent on staff for personal hygiene.

Based on staff interviews, record review, and facility policy review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR) status change for a resident following an inpatient psychiatric hospital stay for one (1) of three (3) PASARRs reviewed. Resident # 57. Findings include: A review of the facility policy titled PASRR Policy and Procedure with a revision date of 7/18/18 revealed, (Facility proper name) uses the most current version of PASRR Rules of the Mississippi Division of Medicaid: Administrative Code, Medicaid Title 23: Part 207, Chapter 1: Long Term Care Pre-Admission Screening as they pertain to the Level 1 (PAS) and Level 2 (PASRR) long term care processes and procedures. Record review of Resident #57's Admission Record revealed that she was admitted to the facility on [DATE] with diagnoses that included Parkinsonism, Anxiety Disorder, Bipolar II Disorder, and Major Depressive Disorder, Recurrent. Record review of Resident #57's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of May 2, 2024, revealed under Section A2105. Discharge Status 07. Inpatient Psychiatric Facility (psychiatric hospital or unit) In an interview on 1/22/25 at 2:45 PM, the former Social Services Director revealed when Resident #57 went out for inpatient psychiatric treatment, she was responsible for completing the PASARRs. She confirmed she did not submit a new change of status form for a Level 2 PASARR because she thought that since the resident had a negative Level I Preadmission Screening (PAS), they were exempt from sending anything further for the resident. During an interview on 1/22/25 at 3:15 PM, the Administrator revealed that the purpose of the Level 2 evaluation is to ensure the residents get the proper psychiatric care they need. He revealed he was unaware that a change in status form was not completed for Resident #57 after her psychiatric hospital stay but confirmed that it should have been.

Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to implement an Activities of Daily Living (ADL) care plan for residents that were dependent on staff for assistance with personal hygiene for five (5) of 21 sampled residents. Resident #15, Resident #31, Resident #55, Resident #67, and Resident #71. Findings Include Review of the facility policy titled, Care Plans, Comprehensive, Person Centered with a revision date of 10/2022 revealed under, Policy Statement .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #15 Record review of Resident #15's Care Plan date initiated 12/27/24 revealed that she had an ADL self-care performance deficit related to weakness and impaired mobility. Resident #15's interventions included that she required partial to moderate assistance by staff for personal hygiene and to offer assistance with any shaving needs. On 01/21/25 at 10:30 AM an observation and interview revealed Resident #15 with numerous scattered facial hairs that were approximately one-half inch long on her chin and upper lip. She stated she use to could take care of it herself, but not anymore. She admitted that no one had offered to shave or remove her facial hair since she had been there and stated, I've been here about a month. On 01/22/25 at 10:38 AM an interview with Registered Nurse (RN) Supervisor #1, confirmed the facial hair on Resident #15's chin and upper lip needed to be removed. She confirmed that shaving is part of grooming during their bath and since it was not done then her ADL care plan was not followed. Record review of Resident #15's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Other Fracture of Right Lower Leg, Unspecified Fall, and Chronic Obstructive Pulmonary Disease. Record review of Resident #15's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated that she had moderate cognitive deficits. Resident #71 Record review of Resident #71's Care Plan date initiated 12/11/24 revealed that he had an ADL self-care performance deficit related to weakness and poor balance. Resident #71's interventions included that he required partial to moderate assistance with personal hygiene and to check nail length and trim and clean on bath day and as necessary. On 01/21/25 at 10:00 AM an observation and interview with Resident #71 revealed long, jagged fingernails that were approximately one-half to three-fourths inch long bilaterally. Resident #71 stated that his fingernails were too long. On 1/22/25 at 10:34 AM, an observation and interview with RN Supervisor #1 confirmed that Resident #71 had long jagged fingernails on both hands. She confirmed that the staff were supposed to take care of their fingernails on bath day and revealed that the residents' ADL care plan was not followed. Record review of Resident #71's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Unspecified Dementia, Parkinson's Disease, and Need for Assistance with Personal Care. Record review of Resident #71's MDS with ARD of 12/16/24 under Section C revealed a BIMS Score of 11 which indicated that he had moderate cognitive deficits. Resident #31 Record review of Resident #31's Care plans revealed, Focus: I have an ADL self-care performance deficit r/t (related to) Cerebral infarction, weakness, need for assistance with personal care .with interventions initiated on 03/11/2020 that included, Perform AM/PM care including oral care, peri-care, bathing, dressing, hygiene, shaving and nail care. On 1/21/25 at 10:05 AM an observation and interview revealed Resident #31's fingernails were long and jagged with a brown substance under every nail. The resident had facial hair that was approximately one inch long on his cheeks, chin, and above the resident's lip and admitted that he had tried to get someone to shave him, but they still have not. Resident #31 stated, I've been trying to get shaved, and I want it all shaved off. On 1/22/25 at 9:15 AM, an interview and observation CNA #1 confirmed that Resident #31 needed to be shaved, and his fingernails needed trimming. She admitted that nail care and shaving is part of grooming. A record review of Resident #31's Admission Record revealed the facility admitted the resident on 09/25/2020 with diagnoses that included Hypertensive Heart Disease with Heart Failure and Major Depressive Disorder. Record review of the MDS with an ARD of 11/29/24 revealed Resident #31 had a BIMS score of 06, which indicated the resident had severe cognitive impairment. Resident #55 Record review of Resident #55's Care plans revealed, Focus: I have an ADL self-care performance deficit r/t weakness, impaired mobility .with interventions initiated on 06/01/2023 that included Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. On 1/21/25 at 10:25 AM an observation and interview with Resident #55's, he stated he likes his fingernails short. An observation at this time revealed the resident's fingernails were all long and jagged. On 1/22/25 at 9:20 AM, an observation and interview CNA #2 confirmed that Resident #55's fingernails on both hands were too long. She revealed his fingernails should be taken care of when he gets his baths. A record review of Resident #55's Admission Record revealed the facility admitted the resident on 05/31/2023 with diagnoses that included Pneumonia, Essential (Primary) Hypertension, and Major Depressive Disorder. Record review of the MDS with an ARD of 11/8/24, revealed Resident #55 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Resident #67 Record review of a care plan for Resident #67 titled, I have an ADL self-care performance deficit r/t (related to) impaired mobility, revealed Interventions: personal hygiene: I am totally dependent on staff for personal hygiene. On 11/21/25 at 9:25 AM, an observation of Resident # 67 revealed the resident had a brown substance on every fingernail on the resident's right hand. On 1/22/25 at 9:40 AM, in an observation and interview with Licensed Practical Nurse (LPN) #2 she confirmed there was a dried brown substance on each fingernail on Resident #67's right hand. She confirmed that Resident #67 had not received nail care and the resident's care plan had not been implemented. Review of the Admission Record revealed Resident #67 was admitted by the facility on 7/29/24 with a diagnosis of Nontraumatic Subarachnoid Hemorrhage. Record review of Resident #67's MDS with an ARD of 11/05/24, revealed GG0130: Self Care : Personal Hygiene: coded 01 Dependent.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide necessary services, to promote healing, and prevention of developing new pressure ulcers for (1) one of (3) three residents with wounds reviewed. (Resident #49) Findings include: Review of the facility policy titled, (Proper Name) Pressure Injury Prevention Program, with a revision date of 09/2024 revealed all residents will be assessed for the risk of pressure injury . specific interventions will be implemented to prevent the development of avoidable pressure injuries, or to treat new/existing pressure injuries. An observation on 1/21/25 at 9:15 AM revealed Resident #49 lying asleep in bed, an air-mattress control box was attached to the foot of the bed, with no lights on indicating the mattress was not on. An observation of the mattress revealed the resident was lying in the middle of the bed, with the mattress completely deflated and sunken in the middle. Review of the Order Summary Report for Resident #49 revealed an active order dated 7/12/23 for a low air loss mattress for pressure redistribution. An observation of Resident #49 on 1/21/25 at 11:20 AM, revealed the mattress remained sunken in the middle, with Resident #49 lying in the sunken area. Certified Nurse Assistant (CNA) #4 was in the room preparing to get the resident out of bed. She revealed the air-mattress was sunken in the middle earlier in the morning before breakfast when she provided care to Resident #49 and admitted that she had not reported that to anyone. An observation and interview on 1/21/25 at 11:25 AM with Licensed Practical Nurse (LPN) #1 revealed Resident #49's air-mattress control box was not on. LPN #1 pushed the buttons on the top of the air-mattress control box and stated she could not get the box to come on. LPN #1 touched the mattress and confirmed that it was deflated. She stated that the resident could develop worsening wounds or skin breakdown from lying on a deflated air mattress. In an observation and interview on 1/21/25 at 11:27 AM with the Maintenance Director, he confirmed Resident #49's air-mattress was deflated because the control box was cut off. He turned the box on, and it immediately came on and inflated the mattress. He then confirmed staff should check the air-mattress often to ensure it is on and functioning and report any concerns. In an interview with the Director of Nursing (DON) on 1/22/25 at 9:48 AM confirmed that Resident #49 could develop worsening of wounds because of his small stature and lead to more skin breakdown from lying on a deflated air mattress. She then confirmed CNA #4 should have reported the mattress being deflated immediately when it was observed. Review of the Admission Record revealed the facility admitted Resident # 49 on 4/13/22 with a diagnosis of Huntington's Disease. Record review of Resident # 49's Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/01/24, revealed Section M: 0300: Number of Stage 4 pressure ulcers coded as (1) one. Item M:1200 was coded as having a pressure reducing device for bed.

Based on observation, resident and staff interview, record review and facility policy review, the facility failed to ensure medications were safely and securely stored for one (1) of three (3) survey days. Findings Include: Record review of the facility policy, Storage of Medications with a reviewed date of July 2024, revealed, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. An observation and interview with Resident #72 on 01/21/25 at 9:35 AM, revealed him lying on his bed in his room and there were ten pills inside a medication cup placed on the top of his over bed table. Resident #72 revealed that the nurse brought his medicine in about five minutes ago and he asked her to leave it there, and he planned to take it in a few minutes. He revealed that the nurse had set the medicine down and left it and a cup of water for him to take it with. An observation and interview on 01/21/25 at 9:40 AM with Licensed Practical Nurse (LPN) #3 confirmed that there were ten pills in a medicine cup on Resident #72's over bed table. She revealed that she had just prepared his 9:00 AM medications and brought them to him. LPN #3 confirmed that she should have stayed in the room and watched him take the medications and not left them with him. She revealed that by leaving medications at the bedside, she would not know what medication the resident took and someone else could come in and take them. LPN #3 confirmed that she was supposed to watch the residents take their medicine and not leave them at the bedside. LPN #3 validated with the Medication Administration Record (MAR) that those medications in the cup were the ones she had just prepared and brought in for Resident #72 to take. An observation and interview with Registered Nurse (RN) Supervisor #2 on 01/21/25 at 9:50 AM confirmed that it was against the facility policy to leave medications at a resident's bedside. She confirmed that there were ten pills in the medication cup left at Resident #72's bedside and that the nurses were supposed to watch the residents swallow the medications before they left the room. RN Supervisor #2 revealed that by leaving medications at the bedside, there was a risk of another resident taking the medications which could possibly be something they were not supposed to have. An interview on 01/22/25 at 2:00 PM with the Director of Nursing (DON), revealed that medications should never be left at a resident's bedside. She revealed that someone else could have rolled in there and taken the medications while the resident was asleep. She went on to say that Resident #72 could have also put off taking them until later when other medications were due and received too much. The DON confirmed that LPN #3 should have watched the resident swallow the pills prior to leaving the room. Record review of Resident #72's Medication Administration Record (MAR) revealed that on 01/21/25 at 9:00 AM, LPN #3 signed out ten medications for administration to Resident #72. Record review of Resident #72's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Major Depressive Disorder, Unspecified Mood Disorder, Anxiety Disorder, and Need for Assistance with Personal Care. Record review of Resident #72's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that he was cognitively intact.

Based on resident, family and staff interviews, record review, and facility policy review, the facility failed to document a summary of the resident's and family's grievances and any corrective actions and follow-up for the grievances for one (1) of three (3) residents reviewed for grievances. Resident #1. Findings include: A record review of the facility's policy titled, Filing Grievances/Complaints with a revised date of 6/2024 revealed, .Our facility will assist residents, their representatives (Sponsors), other interested family members, or advocates in filing grievances or complaints when such request are made . 2. Grievances and/or complaints may be submitted orally, in writing, or electronically and may be filed anonymously.7. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations .11. The resident, or person filing the grievance and/or complaint of behalf of the resident, will be informed verbally and in writing (if requested) of the findings of the investigation and the actions that will be taken to correct any identified problems. Record review of Complaint Intake MS#25961 dated 07/24/24 revealed, We have had four (4) meetings with the Administrator over issues we have had over the last two (2) weeks. A record review of the facility Grievance Log, dated 3/1/2024 to 9/9/2024, revealed no grievances logged for Resident #1. During a phone interview on 9/9/24 at 1:20 PM, Resident #1's husband/Resident Representative (RR) revealed that he had six meetings with the administrator and stated we just got lip service, and nothing is ever resolved when we discussed issues. He revealed the complaints were about the resident being wet or dirty for long periods of time. He stated that the lady in therapy even went and got the administrator several times because my wife would be wet and needed to go to therapy. He revealed when she went to the hospital on 7/31/24, we did not go back to the facility. An interview on 9/9/24 at 2:48 PM the Director of Rehab (DOR) revealed she recalled a time when Resident #1 was first admitted that she went into the resident's room around 9:30 AM to get her for therapy and the resident told me that she needed to be changed first. The DOR confirmed that she had let nursing know and then talked to the administrator about it because I felt like we would have a complaint about it. During an interview on 9/9/24 at 3:55 PM, Registered Nurse (RN) #1 revealed that the family of Resident #1 had frequent complaints. She revealed that on one particular day, she went to the Director of Nurses (DON), and reported a concern voiced by Resident #1's husband about loud, disturbing voices outside of her room. An interview on 9/9/24 at 4:05 PM, the Administrator (ADM) revealed that he was the grievance officer and was aware of the concerns that the family of Resident #1 had voiced and felt like they had addressed them all. He revealed the family would come directly to talk to me about their concerns and that he did not do a formal grievance form and therefore failed to follow-up and ensure the issues were resolved with the RR. An interview on 9/9/24 at 4:15 PM the Director of Nurses (DON) revealed that Resident #1's family did have frequent complaints, she revealed that she felt like we were addressing the issues but confirmed that she had not filled out a proper grievance form and stated, she understands that it is crucial to make sure resident's complaints or grievances are handled in the proper manner and that follow-up is done. A review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Diastolic (congestive) heart failure, Chronic obstructive pulmonary disease, and Type 2 Diabetes Mellitus.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to maintain a clean and comfortable environment, as evidenced by dirty wheelchairs for three (3) of four (4) residents sampled. Resident #2, #3, #4. Findings include: A review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment with a reviewed date of 3/2023 revealed, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection and the OSHA Bloodborne Pathogens Standard . A review of Anonymous Complaint #MS 26061 revealed Wheelchairs are not being cleaned. Resident #2 During an interview on 9/9/24 at 2:00 PM, Certified Nurse Aide (CNA) #1 revealed that the night shift aides are responsible for cleaning the wheelchairs. They have an assignment sheet they are supposed to follow to ensure that all wheelchairs are cleaned. An observation and interview on 9/9/24 at 2:05 PM, revealed Resident #2's wheelchair had a thick gray substance on the frame and the spokes of the wheels. Resident #2 revealed she wasn't sure when her wheelchair was supposed to be cleaned, but it needed it. A record review of Resident #2's Admission Record revealed the resident was admitted on [DATE] with diagnoses including Acute and Chronic Respiratory failure with hypoxia, Unspecified Diastolic (Congestive) heart failure and Bacteremia. Record review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/24, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident is moderately cognitively impaired. Resident #3 An observation and interview on 9/9/2024 at 2:20 PM revealed Resident #3 sitting in his wheelchair, which was noted to have a dried, thick gray substance on its metal base. Resident #3 revealed, Yeah, my chair is dusty. It could use some cleaning. A record review of Resident #3's Admission Record revealed the resident was admitted on [DATE] with diagnoses including Acute and Chronic Respiratory Failure with hypercapnia, Unspecified Diastolic (Congestive) heart failure, and Unspecified Cirrhosis of Liver. Record review of the MDS with an ARD of 08/14/24, revealed Resident #3 had a BIMS score of 14, which indicated the resident is cognitively intact. Resident #4 An observation and interview on 9/9/24 at 3:55 PM, revealed the wheels on Resident #4's wheelchair were cracked and the wheelchair was dirty, with a dark gray substance noted on the frame of the wheelchair and the spokes of the wheels. Resident #4 revealed she had a different wheelchair before she got this one, which was in worse condition. She revealed it needs to be cleaned and also fixed. A record review of Resident #4's Admission Record revealed the resident was admitted on [DATE] with diagnoses including Cerebral infarction, Cerebrovascular disease, Hemiplegia, and Hemiparesis following Cerebral Infarction affecting the right dominant side. Record review of the MDS with an ARD of 08/02/24, revealed Resident #4 had a BIMS score of 9, which indicated the resident is moderately cognitively impaired. In an interview on 9/9/24 at 4:15 PM, the Director of Nurses (DON) confirmed that the wheelchairs are supposed to be cleaned nightly by the CNAs. She revealed that there is an assignment list that they go by, but there is no sign-off sheet to document when it is being done. During an observation and interview on 9/9/24 at 4:55 PM, the Administrator confirmed that the wheelchairs for Residents #2, #3, and #4 were dirty and stated that some of the wheelchairs needed to be repaired as well.

Based on observation, interview, record review and facility policy review the facility failed to ensure a comprehensive care plan was implemented when a Certified Nursing Assistant (CNA) did not check a resident every two hours for incontinence episodes for one (1) of three (3) residents reviewed. Resident #1. Findings Include: Record review of the facility policy, Care Plans, Comprehensive Person-Centered with reviewed date of January 2023 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Record review of Resident #1's Care Plan with an initiation date of 03/19/24, revealed Focus: I am incontinent of bladder .Interventions/Tasks .Check every two (2) hours and as required for incontinence On 04/15/24 at 10:50 AM, an observation revealed Resident #1 lying in his bed on his left side and there was a mild odor of urine noted in the room. His sheet was pulled down with his incontinent brief exposed. The brief was saggy and appeared to be wet. On 04/15/24 at 11:20 AM, an observation revealed Licensed Practical Nurse (LPN) #1 performed wound care to Resident #1's right trochanter. LPN #1 pulled down Resident #1's incontinent brief to prepare for wound care and she confirmed that his incontinent brief was soaked with urine. Resident #1 revealed that he had not been changed since before breakfast. She revealed that the CNAs were supposed to make rounds on the residents every two hours. On 04/15/24 at 11:25 AM, an interview with CNA #1 confirmed that Resident #1 had not been changed since the last shift left at 7 AM that morning. On 04/15/24 at 11:45 AM, an interview with Assistant Director of Nursing (ADON), revealed CNAs were supposed to round on residents every two hours and if the resident refused care, they were supposed to report this to the nurse. The ADON confirmed Resident #1 should be checked at least every two hours. On 04/15/24 at 2:00 PM, an interview with Minimum Data Set (MDS) Nurse, revealed that the purpose of the care plan was to identify the care that each resident needed so the staff would know essentially how to take care of the resident. She revealed that the care plan identified the problems and the conditions of the residents and put individualized interventions in place to follow for each resident. The MDS Nurse also revealed all residents should be checked on at least every two hours whether they were asleep or not and if they refused to be changed, they should be care planned for that as well. The MDS Nurse confirmed that if a resident was not checked on every two hours, the care plan was not followed.

Based on observation, interview, record review and facility policy review the facility failed to ensure Activities of Daily Living (ADL) care was completed on a dependent resident when a Certified Nursing Assistant (CNA) did not check a resident every two hours for incontinent episodes and the resident was left wet for an undetermined amount of time for one (1) of three (3) residents reviewed. Resident #1. Findings Include: Record review of the facility policy titled Activities of Daily Living (ADLs), Supporting revised March 2018 revealed, . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During an observation on 04/15/24 at 10:50 AM, revealed Resident #1 lying in bed and there was a mild odor noted. His bed sheet was pulled down with his incontinent brief exposed and it was sagging and appeared to be wet. During an observation and interview on 04/15/24 at 11:20 AM, revealed Licensed Practical Nurse (LPN) #1 gather supplies and perform wound care to Resident #1's right trochanter. There was a mild odor noted when LPN #1 unfastened the resident's incontinent brief. LPN #1 confirmed the mild odor, and stated, It smells like urine. LPN #1 pulled down Resident #1's incontinent brief to prepare for wound care and she confirmed that his brief was soaked with urine. Resident #1 stated that he had not been changed since before breakfast. During an interview on 04/15/24 at 11:25 AM, CNA #1 confirmed Resident #1 was assigned to her and she had not changed him yet because he was sleeping. CNA #1 confirmed that he had not been changed since the last shift left at 7 AM that morning. She revealed that she didn't get him up because he didn't like to be woken up. During an interview on 04/15/24 at 11:45 AM, the Assistant Director of Nursing (ADON), revealed that CNAs were supposed to round on residents every two hours and if the resident refused care, they were supposed to report this to the nurse. She revealed that leaving a resident wet for extended periods could cause the wounds to get worse and could cause infection. The ADON revealed that Resident #1 was normally up and on the move but he still should be checked at least every two hours. She revealed that even if residents were sleeping, they were required to check and see if they needed to be changed. She revealed that it was unacceptable for a CNA to leave a resident for hours without checking on them and changing their brief. She revealed that they would educate and in-service about this. She stated, They can't not change them. She revealed that it was unacceptable for a CNA to leave a resident over four hours without checking on them and changing their brief. During an interview on 04/15/24 at 11:55 AM, the Director of Nursing (DON) revealed CNAs are required to check on residents every two hours that are incontinent and see if they needed changing. She revealed that CNA #1 should have rounded on Resident #1 and changed him even if he was asleep. During an interview on 04/15/24 at 3:09 PM, CNA #2 revealed that they were supposed to round on all residents every two hours and change them whether they were asleep or not because residents could be at risk for skin breakdown. Record review of Resident #1's Admission Record revealed that he was admitted on [DATE] and had diagnoses that included Huntington's Disease, Spina Bifida, Stage 3 Pressure Ulcer of Right Hip, and Need for Assistance with Personal Care. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/24, Section C revealed a Brief Interview for Mental Status (BIMS) score of 09 which indicated he had moderate cognitive deficits.

Based on staff interviews, record review, and facility policy review the facility failed to ensure a resident with a history of choking on [DATE] was ordered a therapeutic diet to prevented a choking incident on [DATE] and again on [DATE] which required Cardiopulmonary resuscitation, and hospitalization with a poor recovery prognosis for one (1) of six (6) residents reviewed for diets. The facility failed to identify a choking incident on [DATE] with required hospitalization for three (3) days and removal of a food bolus from his oropharynx and failed to identify an [DATE] choking incident that required the Heimlich maneuver to remove the food bolus from his oropharynx in the facility. This failure resulted in the resident not receiving services to prevent choking episodes. The resident's diet was changed on [DATE] to Consistent Carbohydrate Diet (CCD) mechanical soft. The resident's diet changed on [DATE] to CCD with chopped meats and the Certified Nursing Assistants (CNA) were to chop the resident's meat when the tray was served. The meal tickets were never changed to include the CNA to chop meats. On [DATE] in the evening, Resident #13 was served an Italian Sausage link that was five (5) to six (6) 1 ,d+[DATE] inch chunks of meat and the resident was found in his bed, unable to breath and without a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was performed for over ten (10) minutes and Resident #13 was transported to the local hospital where the resident was placed on life support. The facility's failure to ensure that staff were aware of the diet needs of Resident #13 and to clarify and serve the correct diet order to a resident with a history of choking and dysphagia resulted in Resident #13 choking on [DATE] and required life saving measures The resident remained in the hospital on the ventilator at the time of the survey. The situation was identified as an Immediate Jeopardy (IJ) that began on [DATE] when the facility failed to ensure Resident #13 received a modified diet after a choking episode. On [DATE] at 3:35 PM, the State Agency notified the facility's Administrator of the IJ and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged all corrective actions were completed to remove the IJ on [DATE], and the IJ was removed on [DATE]. The State Agency (SA) validated the removal plan on [DATE], prior to exit. and the scope and severity for F803 was lowered to a 'D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Cross Reference F600 Review of the facility policy titled, Food and Nutrition Services dated [DATE], revealed, Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident Policy Interpretation and Implementation: 7 .Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident . Review of the facility policy titled, Diet and Nutrition Care Manual Dysphagia Advanced (level 3) or Mechanical (Dental) soft diet dated 2019 revealed, This diet is used for individuals with mild oral and/or pharyngeal phase dysphagia. Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow . Review of the facility policy titled, Therapeutic Diets dated [DATE] revealed, the diet order should match the terminology used by the food and nutrition services department. Record review of the Diet Requisition Form New admitted d [DATE] revealed Resident #13 had a regular consistent carbohydrate (CCD) regular texture, thin liquids diet. Record review of the local hospital emergency room Report, dated [DATE], read chief complaint: Altered Mental Status. Rehab facility was contacted for further information regarding patient's presentation, and they reported that patient had abnormal moaning and jerking-like motions, and that staff had concerns for new onset seizure-like activity. Per chart review, patient has no prior history of seizures but does have a history of Cerebral Vascular Accident (CVA) involving left middle cerebral artery. At the time of exam, it was noted that the patient had a golf ball sized food bolus extracted from posterior oropharynx. Record review of Progress notes dated [DATE] at 18:20 PM, revealed, Resident noted with choking episode this shift at dinner time. Licensed Practical Nurse (LPN) reporting that the resident had gotten choked on a piece of meat off his dinner tray. LPN assist resident with dislodging piece of meat. Resident's color returning to normal with O2 (oxygen) saturation of 97% on RA (room air). Resident continued to be noted with a cough. Record review of the Diet Requisition Form Diet Change, dated [DATE], revealed Resident #13 was changed to a Mechanical soft chopped meat texture diet. Record review of a Meal Ticket, dated [DATE] at 2:34 PM, revealed diet order was changed to Chopped Meats; Knife and resident was served whole meats with a knife to cut. Record review of Progress Note dated [DATE] at 13:48 PM read, It was reported to ST (Speech Therapy) that the pt got choked while eating meat the previous day. Also nurse reports pt had difficulty while taking meds today. Record review of Resident #13's meal ticket dated [DATE] all meals CCD-Mechanical Soft. Review of the Dinner meal ticket revealed- Ground Italian Sausage, brown gravy, parmesan noodles, broccoli florets chopped and sliced pears. The same meal was served on [DATE], the evening that the resident choked, and review of the dinner meal ticket revealed, Italian Sausage, Parmesan noodles, Broccoli florets, sliced pears. Record review of Progress Notes, dated [DATE] at 19:42 PM stated, Nurse was alerted by CNA that I was needed in resident's room. Upon arriving in room resident appeared to be having seizure activity. Pulse was faint and respirations noted. Resident had foamy secretions coming from mouth. Resident was pale in color. CNA told this nurse that prior to her alerting me he had been eating. This nurse performed back thrust times 5 and was in process of performing ABD (abdominal) thrust when other help arrived. Thrust was ineffective. Nurse left room and got crash cart and upon returning CPR was in process related to no pulse or respirations. Progress note for [DATE] at 19:45 PM Nurse observed resident unresponsive, pale and foaming at the mouth. Nurse called 911 and returned to aid with chest compression until EMS arrived. Record review of the local hospital emergency room report dated [DATE] stated, History of Present Illness .Per ambulance run report: Patient was found lying supine in bed upon arrival; nursing home staff stated that the patient was found unresponsive and cyanotic immediately after mealtime. Per ED (Emergency Department) sign out: Patient was exhibiting agonal breathing; a piece of sausage was extracted from his oropharynx prior to intubation . During the intubation, we visualized a very large piece of food obstructing the patient's airway, using forceps, and removed the foreign body. After the patient was intubated and sedated and placed on the ventilator, his vital signs normalized . In an interview on [DATE] at 12:50 PM CNA # 2 revealed she had never been in-serviced on how to chop the resident's meats before and wasn't aware that he was supposed to have his meats chopped because the diet ticket never said to chop his meats. In an interview on [DATE] at 1:40 PM with CNA #7 revealed the day before he choked on [DATE], he had a whole piece of chicken that was served on his meal tray. She stated we never cut his meat up before and the resident can eat by himself, and we don't stay in the room with him while he is eating. In an interview on [DATE] at 8:10 AM, CNA #8 revealed she was never aware that the resident required his meats to be chopped before he choked on [DATE]. She revealed we were told after he choked that we needed to make sure and chop his meats, but not before. In an interview on [DATE] at 8:25 AM with Dietary management Service Account Manager revealed she has been here for about two months and stated that when she started, she was told anyone with a chopped meats diet we were to put a whole piece of meat on the plate and put a knife on the tray so that the CNA could cut up the meat. She revealed this was the only place she had ever worked that a CNA would cut the meat up. She stated on [DATE] she was in the kitchen and did observe the meal which consisted of Italian sausage that was cut into about one (1) to one and one-half (,d+[DATE]) inch chunks and each resident got about three or four chunks of the meat on their tray. An interview, on [DATE] at 8:50 AM, with CNA #6 revealed that she was working the night of [DATE] and went into Resident #13's room at about 7:15 PM to get his vital signs. The resident said he was hungry. CNA #6 stated she assisted him to the bathroom and then set up his tray which consisted of noodles, round Polish sausage there were about four large round pieces about ,d+[DATE] inch to one inch long on his tray, and broccoli florets. She revealed she didn't cut the sausage up because she was not aware that he required his meat to be chopped or cut. She revealed I went and started getting his roommate's vital signs and then she heard Resident #13 make a sound I never had heard before. She stated she thought he was having a seizure because he had fallen back on his bed rail and was foaming out of the mouth. I went for help immediately. She revealed on his plate he had eaten all the sausages and maybe one of the broccoli florets. She stated that after this incident we were in-serviced to make sure to look on the meal ticket and that CNAs were responsible for chopping meat for residents requiring chopped meats. She confirmed before the choking incident they were not told to cut the residents' meats up. She stated she had worked here for about a year and had never been told to chop his meats before and hadn't seen his meats chopped up. In an interview on [DATE] at 9:30 AM, the Administrator (ADM) revealed Speech Therapy had ordered a chopped meats diet in August because the resident had a choking episode. She revealed the Dietary Director of Operations told her they were not able to do a chopped meats diet. She revealed we immediately in-serviced the staff that the kitchen would send out the appropriate knife and they would have to chop the meats. She stated, I did not feel comfortable with my staff cutting the meats, but I was told by the Dietary Director of Operations that it was a facility policy but since then I found out that wasn't true. She confirmed that she found out that wasn't true through my Corporate Chief Operating Officer and stated, I didn't say anything to the Dietary Director of Operations after that because that's a corporate-level issue and I was letting them handle it. She stated, I could make it happen today to stop all chop meats and just do a Mechanical soft. I haven't done it yet because Corporate had been working with Dietary Management about the issue. She revealed that since the incident that happened on [DATE] with Resident #13 the aides are still chopping meat for the residents and stated that we keep a list of residents who require chopped meats at the nurse's station. She confirmed when she found out on [DATE] that the resident had choked, she hadn't done anything different with the chopped meat diets because corporate is working on that. In an interview on [DATE] at 10:05 AM, with the Director of Operations (DO) for the dietary services management company revealed that the management company has three diets which are Regular, Mechanical Soft, and Pureed. He stated that Resident #13 was put on a chopped meat diet on [DATE], because he had a choking episode. He confirmed that he had asked the Administrator for a diet clarification because we do not historically do chopped meats, we could do mechanical soft, and he was told by the Administrator to send out a knife for the residents who were on a chopped meat diet and the aides would chop the meats. He confirmed that this occurred on the Thursday before Labor Day, which would have been [DATE]. The Director of Operations revealed he is over 23 buildings, and this is the only building where they are doing chopped meats and requiring aides to chop the meat when it gets to the resident. In an interview on [DATE] at 12:55 PM, with the Nurse Consultant, Director of Nurses (DON), and Administrator revealed they were not aware of the choking episode on [DATE]. The DON and Nurse Consultant revealed they were not aware of a choking episode on [DATE]. The Administrator revealed she was aware of the [DATE] choking episode and had a conversation with the Dietary because Speech Therapy had evaluated Resident #13 and requested a chopped meat diet. In an interview on [DATE] at 2:05 PM with CNA #7 revealed she never saw on the electronic charting guide for Resident #13 that the CNA was to chop meats. She revealed our tablets are how we know how to chart for the residents and what they are supposed to get. In an interview on [DATE] at 4:00 PM, Registered Nurse (RN) #2 revealed on [DATE] was the Nurse Supervisor; she stated the floor nurse hollered for me and said she had done the Heimlich maneuver on Resident #13 and was able to get the food expelled. She stated they put in a diet order change the next day for chopped meats. Record review of Resident #13's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Transient Cerebral Ischemic Attack, Dysphagia, Altered Mental Status, and Unspecified Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had a severe cognitive impairment. The assessment further indicated under Section GG that Resident #13 required for eating, supervision, or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. The assessment further indicated under Section K that Resident #13 had coughing or choking during meals or when swallowing medication and complaints of difficulty or pain with swallowing. Removal Plan: On [DATE] at 3:35 PM, the Facility Administrator was notified that the situation of neglect for Resident #13 was deemed an Immediate Jeopardy (IJ). The Facility submitted the following Removal Plan: 1. On [DATE] at 3:00pm, the Minimum Date Set (MDS) Nurse audited diet orders for residents that require chop meats and ensured that it is on the Kardex and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the Kardex and Care Plan by the MDS Nurse. 2. On [DATE] at 3:00pm, Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. On [DATE] at 7:30pm, Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. On [DATE] at 8:00am, Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). 5. On [DATE] at 1:00pm, Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. On [DATE] at 8:00 am, Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. On [DATE] at 11:22 am, Medical Director gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. On [DATE] at 1:00pm, Minimum Date Set (MDS) Nurse updated diets for all residents in facility on Mechanical Soft diet on Kardex and Care Plan. 9. On [DATE] at 1:00pm, Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. On [DATE] at 5:00pm, Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist and the Medical Director. 11. On [DATE] at 4:00pm, Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from [DATE] to [DATE] to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on [DATE] at 10:00 am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective [DATE]. 13. The weekend Registered Nurse was in-serviced on [DATE] at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The Regional Clinical Services counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on [DATE] at 10:00 am. 15. The Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on [DATE] at 4:00pm. 16. All in-services that have been initiated will have 100% completion by [DATE]. NO employees will be allowed to work until in-serviced. The facility alleges that all corrective actions were completed as of [DATE] and the Immediate Jeopardy removed on [DATE]. 1. The State Agency (SA) validated through record review and interview on [DATE] at 9:12 AM with the Minimum Date Set (MDS) Nurse that the diet orders were audited for residents that require chop meats and ensured that it is on the Kardex and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the Kardex and Care Plan by the MDS Nurse. 2. The SA validated on [DATE] at 9:24 AM through record review and interview that the Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. The SA validated on [DATE] at 9:24 AM through interview and record review that the Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. The SA validated on [DATE] at 9:27 AM through interview that the Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). Record review of these in-services were validated by the SA. 5. The SA validated Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. The SA validated through interviews and record review on [DATE] that Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. The SA validated through interview and record review on [DATE] with the Medical Director that he gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. The SA validated through record review and interview on [DATE] with the Minimum Date Set (MDS) Nurse that updated diets for all residents in facility on Mechanical Soft diet are on Kardex and Care Plan. 9. The SA validated that the Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. The SA validated through record review and interviews on [DATE] that an Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist and Medical Director. 11. The SA validated through interview on [DATE] with the Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from [DATE] to [DATE] to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The SA validated through record review and interview on [DATE] that the Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on [DATE] at 10:00am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective [DATE]. 13. The SA validated through record review and interview on [DATE] that the weekend Registered Nurse was in-serviced on [DATE] at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The SA validated through record review and interview on [DATE] with the Regional Clinical Services that she counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on [DATE] at 10:00 am. 15. The SA validated through record review and interview on [DATE] that the Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on [DATE] at 4:00pm. 16. All in-services that have been initiated will have 100% completion by [DATE]. NO employees will be allowed to work until in-service is completed.

Based on staff interviews, record review, and facility policy review the facility failed to implement a care plan for for two (2) of 18 care plans reviewed as evidenced by (1) the facility failed to develop and implement a care plan for a resident with a history of choking on [DATE] and [DATE] resulting in the resident experiencing a choking episode on [DATE] which required Cardiopulmonary Resuscitation and hospitalization with a poor recovery prognosis. Resident #13. (2) the facility also failed to implement a care plan regarding shaving and nail care for a resident that required assistance with ADL's (Activities of Daily Living) for Resident #30. The facility failed to implement care plans for Resident #13 following a choking incident on [DATE] with required hospitalization for three (3) days and removal of a food bolus from his oropharynx and on [DATE] choking incident that required the Heimlich maneuver to remove the food bolus from his oropharynx in the facility. This failure to implement a care plan resulted in the resident not receiving services to prevent choking episodes. The resident's diet was changed on [DATE] to Consistent Carbohydrate Diet (CCD) mechanical soft. The resident's diet changed on [DATE] to CCD with chopped meats and the Certified Nursing Assistants (CNA) were to chop the resident's meat when the tray was served. The meal tickets were never changed to include the CNA to chop meats. On [DATE] in the evening, Resident #13 was served an Italian Sausage link that was five (5) to six (6) 1 ,d+[DATE] inch chunks of meat and the resident was found in his bed, unable to breath and without a pulse or respirations. The facility performed Cardiopulmonary Resuscitation (CPR) for approximately ten (10) minutes and Resident #13 was transported to the local hospital where he remained on life support. The facilities failure to implement the care plan to sit up at meals, supervision, and to serve the correct diet order to a resident with a known history of choking in the facility and dysphagia resulted in Resident #13 choking on [DATE] and required life saving measures and remained in the hospital on the ventilator at the time of the survey. This failure resulted in harm for Resident #13 and placed other residents at risk in a situation that was likely to cause serious harm, injury, impairment or death. The situation was identified as an Immediate Jeopardy (IJ) that began on [DATE], when the facility failed to implement care plans for a resident with dyphasia who had a history of choking. On [DATE] at 3:35 PM, the State Agency notified the facility's Administrator of the IJ and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged all corrective actions were completed to remove the IJ on [DATE] and the IJ was removed on [DATE]. The State Agency (SA) validated the removal plan on [DATE], prior to exit. and the scope and severity for F656 was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy, titled Care Plans, Comprehensive Person-Centered dated ,d+[DATE]: Reviewed [DATE] revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1 .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The IDT includes: a. The attending physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; a member of the food and nutrition services staff; e. The resident and the resident's legal representative (to the extent practicable); and f. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident . Resident #13 Cross Reference F600 Record review of Resident #13's care plan revealed Focus: The resident has risk for nutritional problem or potential nutritional problem r/t (related to) .DYSPHAGIA following CVA (cerebrovascular accident) .Interventions . CCD diet, Chopped Meat texture, Thin Consistency (undated) CNA to Chop meats. Date initiated [DATE] .Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Date initiated: [DATE] .Provide and serve diet as ordered. Date initiated: [DATE] .Resident to be up in w/c (wheelchair) for all meals d/t (due to) aspiration precautions Date initiated: [DATE] .Staff to assist patient with self-feeding with all meals Date initiated: [DATE] . Record review of Resident #13's care plan Focus: The resident has an ADL (activity of daily living) self-care performance deficit . Interventions .EATING: The resident requires (supervision assistance) by (1) staff to eat. Date initiated [DATE] . Record review of Resident #13's care plan Focus: I have alteration in my respiratory status r/t XXX[DATE]-choking episode noted during meal on meat . Record review of Progress Notes, dated [DATE] at 10:16 AM stated, Resident is to be gotten up for meals in W/C (wheelchair). Record review of Progress Note dated [DATE] at 13:48 PM revealed, It was reported to ST (Speech Therapy) that the patient got choked while eating meat the previous day. Also nurse reports patient had difficulty while taking meds today. Record review of Resident #13's meal ticket, dated [DATE], all meals CCD-Mechanical Soft. Review of the Dinner meal ticket revealed- Ground Italian Sausage, brown gravy, parmesan noodles, broccoli florets chopped and sliced pears. The same meal was served on [DATE] the evening that the resident choked, and review of the dinner meal ticket revealed, Italian Sausage, Parmesan noodles, Broccoli florets, sliced pears. During an interview on [DATE] at 2:05 PM, with CNA #7 revealed she never saw on the electronic charting guide for Resident #13 that directed the CNA to chop meats. She revealed facility CNA tablets are how CNAs know how to chart for the residents and what they are supposed to get, but that was not showing on the tablets. During an interview, on [DATE] at 2:15 PM, with CNA #4 revealed I've never seen chopped meats listed on the tablets that we use to document. During an interview on [DATE] at 2:35 PM, the Minimum Data Set (MDS) nurse updated the care plan on [DATE] to be up in w/c for all meals and stated that she put it in there when he had his quarterly MDS. She revealed I think we also may have talked about it in the morning meeting, but I'm not sure. During an interview on [DATE] at 4:00 PM, Registered Nurse (RN) #2 revealed on [DATE] was the Nurse Supervisor when the resident choked that night and stated they put in a diet order change the next day for chopped meats and confirmed the order put in for care plans for him to be set up in the wheelchair was due to the choking episode on [DATE]. She revealed she was unaware of the choking episode for Resident #13 in June and stated we have a daily stand-up meeting where all disciplines attend including the Administrator, DON, and Assistant Director of Nursing (ADON). She confirmed I'm not sure if it was discussed in the morning stand-up meeting or the clinical standards meeting about him choking on [DATE] but all the nursing knew about it and his care plan to be up in his wheelchair for all meals. During an interview on [DATE] at 4:15 PM, the DON confirmed after the [DATE] incident she instructed Resident #13's care plan to be updated to make sure it read for the CNA to chop meats was reflected on his meal tickets and that she was the one that put it on his [DATE] meal ticket for CNA to chop meats, and confirmed that it was not on there for the CNA to see that day. She confirmed it was not on the care plan before [DATE] and it should have been. During an interview on [DATE] at 8:30 AM, the DON revealed she was not aware that the resident had a choking episode in June or in August and revealed she didn't know that the care plan was updated in June for the staff to assist him with all meals or the care plan updated in August for him to be up in the wheelchair for all meals. She revealed the Interdisciplinary Team (IDT) team is involved in care plan meetings and confirmed the care plan was not being followed. She revealed she is usually informed of any changes during the stand-up meeting each morning and revealed, I don't know how the incident in June and August was missed. The DON stated, I guess it was a breakdown in communication. The DON confirmed she did instruct the staff to update the Resident's care plan on [DATE] for the CNA to Chop the meat. She revealed when it is in the care plan it pulls to the CNA's Kardex. She confirmed it was not in the care plan prior to the incident on [DATE] and it should have been. She confirmed that the CNAs would not have any way of knowing how to chop the meats until they corrected it on [DATE]. During an interview on [DATE] at 12:07 PM, the Social Worker revealed they normally keep sign-in sheets for the care plan meeting, but she does not have one for the [DATE] quarterly care plan meeting. She stated when she had the care plan meeting with Resident #13, it was just the two of them. She revealed if the family is coming, then all necessary disciplines will meet with the family. During an interview on [DATE] at 12:15 PM, the MDS nurse revealed she was not at Resident #13's quarterly care plan meeting on [DATE] and revealed she usually does not attend the resident care plan meetings only if she is requested to attend. She revealed she did put in the care plan in August that the resident was to be up in wheelchair (w/c) for all meals related to (d/t) aspiration precautions and that was probably because we discussed it in the morning meeting about his choking episode in August. She stated the morning meetings consist of all department heads, including the DON and the Administrator, we discuss anything from the 24-hour report that is significant. She stated, I'm sure everyone was aware of him choking which was a significant issue. Record review of Resident #13's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Transient Cerebral Ischemic Attack, Dysphagia, Altered Mental Status, and Unspecified Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had a severe cognitive impairment. The assessment further indicated under Section GG that Resident #13 required for eating, supervision, or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. The assessment further indicated under Section K that Resident #13 had Coughing or choking during meals or when swallowing medication and complaints of difficulty or pain with swallowing. Resident #30 Record review of Resident #30's care plans revealed the resident had a care plan that indicated the resident has an ADL self-care deficit related to a CVA (Cerebrovascular Accident) and left sided weakness, encephalopathy and dementia with an initiation date of [DATE]. The interventions for this care plan included that the resident required total assistance by one staff with bathing/showering and extensive assistance by one staff with personal hygiene. During an observation and interview on [DATE] at 11:30 AM, revealed Resident #30 had facial hair that was approximately ,d+[DATE] inch long on the resident's chin and sides of his face. Bilateral fingernails were approximately ,d+[DATE] inch long and had a brown substance under 4 nails. Resident #30 stated that he was not sure when he was last shaved or when his nails were last trimmed. During an observation and interview on [DATE] at 9:15 AM, revealed Resident #30 with no change in appearance from the previous day. He stated he is supposed to be shaved when he is showered but it doesn't always happen. He revealed he likes his nails trimmed and has tried to cut them himself with a pair of toenail clippers. He revealed the treatment nurse trimmed them once before. During an observation and interview on [DATE] at 9:25 AM, with Certified Nurse Assistant (CNA) #2 revealed she is assigned to Resident #30 today. She confirmed that the resident looked like he had not been shaved in a while and that his fingernails were long and needed to be trimmed. During an interview on [DATE] at 3:50 PM with Licensed Practical Nurse (LPN) #4 revealed the purpose of the care plans were to see what is needed to care for the residents and to make sure those needs are met. He stated that all staff have access to the care plans including the CNA's. He revealed that if a resident was supposed to be shaved and was not then their care plan was not implemented. During an interview on [DATE] at 4:00 PM with CNA #5 revealed the CNA's have access to the care plans and the resident care plans are to be followed for care needed and to make sure everything goes as it is supposed to. She confirmed that if a resident was not shaved and needed assistance then the resident's care plan would not have been implemented. Record review of Resident #30's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Major Depressive Disorder and Need for Assistance with Personal Care. Record review of Resident #30's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed in Section C a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident is moderately cognitively intact and in Section GG that the resident needs substantial/maximal assistance with showers/bathe self. The Facility submitted the following Removal Plan: 1. On [DATE] at 3:00pm, the Minimum Date Set (MDS) Nurse audited diet orders for residents that require chop meats and ensured that it is on the Kardex and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the Kardex and Care Plan by the MDS Nurse. 2. On [DATE] at 3:00pm, Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. On [DATE] at 7:30pm, Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. On [DATE] at 8:00am, Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). 5. On [DATE] at 1:00pm, Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. On [DATE] at 8:00am, Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. On [DATE] at 11:22am, Medical Director gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. On [DATE] at 1:00pm, Minimum Date Set (MDS) Nurse updated diets for all residents in facility on Mechanical Soft diet on Kardex and Care Plan. 9. On [DATE] at 1:00pm, Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. On [DATE] at 5:00pm, Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist, and the Medical Director. 11. On [DATE] at 4:00pm, Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from [DATE] to [DATE] to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on [DATE] at 10:00am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective [DATE]. 13. The weekend Registered Nurse was in-serviced on [DATE] at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The Regional Clinical Services counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on [DATE] at 10:00am. 15. The Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on [DATE] at 4:00pm. 16. All in-services that have been initiated will have 100% completion by [DATE]. NO employees will be allowed to work until in-serviced. The facility alleges that all corrective actions were completed as of [DATE] and the Immediate Jeopardy removed on [DATE]. The state Survey Agency (SA) validated the removal of the immediacy. 1. The State Agency (SA) validated through record review and interview on [DATE] at 9:12 AM with the Minimum Date Set (MDS) Nurse that the diet orders were audited for residents that require chop meats and ensured that it is on the Kardex and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the Kardex and Care Plan by the MDS Nurse. 2. The SA validated on [DATE] at 9:24 AM through record review and interview that the Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. The SA validated on [DATE] at 9:24 AM through interview and record review that the Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. The SA validated on [DATE] at 9:27 AM through interview that the Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). Record review of these in-services were validated by the SA. 5. The SA validated Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. The SA validated through interviews and record review on [DATE] that Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. The SA validated through interview and record review on [DATE] with the Medical Director that he gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. The SA validated through record review and interview on [DATE] with the Minimum Date Set (MDS) Nurse that updated diets for all residents in facility on Mechanical Soft diet are on Kardex and Care Plan. 9. The SA validated that the Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. The SA validated through record review and interviews on [DATE] that an Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist and Medical Director. 11. The SA validated through interview on [DATE] with the Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from [DATE] to [DATE] to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The SA validated through record review and interview on [DATE] that the Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on [DATE] at 10:00am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective [DATE]. 13. The SA validated through record review and interview on [DATE] that the weekend Registered Nurse was in-serviced on [DATE] at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The SA validated through record review and interview on [DATE] with the Regional Clinical Services that she counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on [DATE] at 10:00am. 15. The SA validated through record review and interview on [DATE] that the Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on [DATE] at 4:00pm. 16. All in-services that have been initiated will have 100% completion by [DATE]. NO employees will be allowed to work until in-service is completed. 46013

Based on staff interview, record review, and facility policy review, the facility failed to be administered in a manner to prevent negligent care to a resident and to ensure staff were made aware of significant incidents and the dietary needs of Resident #13 for one (1) of three (3) residents reviewed for abuse/neglect. Resident #13 Resident #13 had choking episodes on [DATE] which resulted in the hospitalization where a golf ball size meat bolus was removed in the emergency room . Resident #13 choked on meat again on [DATE] which was removed in the facility with the Heimlich Maneuver. The resident's diet was changed on [DATE] to Consistent Carbohydrate Diet (CCD) mechanical soft. The Administrator requested the resident's diet changed on [DATE] to CCD with chopped meats and the Certified Nursing Assistants (CNA) were to chop the resident's meat when the tray was served. The meal tickets were never changed to include the directions for CNA to chop meats. On [DATE] in the evening, Resident #13 was served an Italian Sausage link that was five (5) to six (6) ,d+[DATE] inch chunks of meat and the resident was found in his bed, unable to breath and without a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was performed for over ten (10) minutes and was not successful. Resident #13 was transported to the local hospital where he remained on life support. The hospital report revealed the resident had choked again. This situation was identified as an Immediate Jeopardy (IJ) that began on [DATE] when the Administration failed ensure measures were put into place to prevent further choking episodes. The facility's failure to be administered in a way to ensure a resident was protected from further choking incidents resulted in harm to Resident #13 and the likelihood of serious harm, impairment, or death to other residents. On [DATE] at 3:35 PM, the State Agency notified the facility's Administrator of the IJ and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged all corrective actions were completed to remove the IJ on [DATE], and the IJ was removed on [DATE]. The State Agency (SA) validated the removal plan on [DATE], prior to exit. and the scope and severity for F835 was lowered to a 'D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Cross Reference F600 Record review of facility policy, dated [DATE], Job Description Position Title: Facility Administrator revealed, Basic Function- Responsible for the overall management, leadership, growth, and profitability of the facility . Essential Functions and Responsibilities: .Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines . Ensures that the quality and appropriateness of resident care meets or exceeds company and industry standards and ensures that all services are in compliance with state and federal legal, regulatory, accreditation and reimbursement guidelines . Report incident reports to proper company and agency authorities in accordance with regulatory guidelines. Attend and/or conduct facility meetings, as required to carry out responsibilities. Promotes optimal communication among staff members, facility staff, referral sources physicians and residents. Record review of facility policy, dated [DATE], titled, Job Description Position Title: Director of Nursing revealed, Function: Plans, coordinates and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to the Residents .Care and Services: Responsible for the overall direction, coordination and evaluation of the nursing department . Schedules and performs Resident rounds to monitor and evaluate the quality and appropriateness of nursing care. Maintains administrative authority, responsibility and accountability for the proper charting and documentation of care and of medications and treatments. Record review of facility policy, dated ,d+[DATE], titled, Position Description Position Title: Assistant Director of Nursing revealed, The primary purpose of your job position is to assist the Director of Nursing Services in planning organizing, developing, and directing the day-to-day functions of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator, the Medical Director, and/or Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times . Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided . Participate in developing, planning, conducting, and scheduling in-service training classes that provide instructions on how to do the job, and ensure a well-educated nursing service department . The Administrator (ADM) in an interview on [DATE] at 9:30 AM, revealed Speech Therapy had ordered a chopped meats diet in August because the resident had a choking episode. She revealed the dietary management company's Dietary Director of Operations told her they were not able to do a chopped meats diet. She revealed we immediately in-serviced the staff that the kitchen would send out the appropriate knife and they would have to chop the meats. She stated, I didn't feel comfortable with my staff cutting the meats, but I was told by the Dietary Director of Operations that it was a facility policy but since then I found out that wasn't true. She confirmed that she found out that wasn't true through Corporate and stated, I didn't say anything to the Dietary Director of Operations after that because that's a corporate-level issue, and I was letting them handle it. She stated, I could make it happen today to stop all chop meats and just do a Mechanical soft. I haven't done it yet because Corporate had been working with the dietary company about the issue. She revealed that since the incident that happened on ,d+[DATE] with Resident #13 the aides are still chopping meat for the residents and stated that we keep a list of residents who require chopped meats at the nurse's station. She confirmed when she found out on [DATE] that the resident had choked, she had not done anything different with the chopped meat diets because corporate is working on that. The Director of Operations (DO) for Dietary with the dietary management company stated in an interview on [DATE] at 10:05 AM, that the company has three diets which are Regular, Mechanical Soft, and Pureed. He stated that Resident #13 was put on a chopped meat diet on [DATE], because he had a choking episode. He confirmed that he had asked the Administrator for a diet clarification because dietary does not historically do chopped meats, but could do mechanical soft, and he was told by the Administrator to send out a knife for the residents who were on a chopped meat diet and the aides would chop the meats. He confirmed that this occurred on the Thursday before Labor Day, which would have been [DATE]. The Director of Operations for Dietary revealed he is over 23 buildings, and this is the only building where they are doing chopped meats and requiring aides to chop the meat when it gets to the resident. He stated that he did not like sending knives out for CNAs to cut up meat but he was unable to get the Administrator to understand that chopped meats is considered a mechanical soft diet. The Director of Operations (DO) for Dietary stated he just needed the Administration to get the diet order clarified. The Nurse Consultant, Director of Nurses, and Administrator revealed during an interview on [DATE] at 12:55 PM, they were not aware of the choking episode on [DATE]. The DON and Nurse Consultant revealed they were not aware of a choking episode on [DATE]. The Administrator revealed she was aware of the [DATE] choking episode and had a conversation with the Dietary because Speech Therapy had evaluated Resident #13 and requested a chopped meat diet. Registered Nurse (RN) #2, in an interview on [DATE] at 4:00 PM, revealed she was unaware of the choking episode for Resident #13 in June and stated we have a daily stand-up meeting where all disciplines attend including the Administrator, DON, and Assistant Director of Nursing (ADON). She confirmed I'm not sure if it was discussed in the morning stand-up meeting or the clinical standards meeting about him choking on [DATE]. The Administrator revealed during an interview on [DATE] at 4:10 PM, for the incident on [DATE] she was not made aware that Resident #13 was eating dinner when the episode occurred, until the next day, on [DATE], around lunch time. She confirmed the nurse told her that he had a seizure and the facility had to do CPR and send Resident #13 to the hospital. She had seen the hospital paperwork on [DATE] that revealed he had the sausage in his oropharynx and revealed for the [DATE] incident the staff nurses just reported that he got strangled on his food and that's when he got the order for speech to be evaluated. She confirmed she was not aware that Resident #13 required the Heimlich maneuver at that time. The DON revealed in an interview, at the same time, on [DATE] at 4:10 PM, that for the [DATE] incident she was made aware that the resident had trouble with taking his medicines and was not made aware of him choking. She revealed she is going to start going back and reading the nurse's notes each day so she will know what is going on. She revealed it usually will come out on the 24-hour nurses report and we will discuss it in the morning meeting. The DON and Administrator both revealed they were not sure how the choking episodes got missed. The DON confirmed after the [DATE] incident she instructed Resident #13's care plan to be updated to make sure CNA to chop meats was reflected on his meal tickets and that she was the one that put it on his [DATE] meal ticket for CNA to chop meats, and confirmed that it was not on there for the CNA to see that day. She confirmed it was not on the care plan before [DATE] and it should have been. She confirmed again that she was not aware of Resident #13 having a choking episode in June or August and that she wasn't aware that he had choked on [DATE] until the afternoon on [DATE]. An interview on [DATE] at 8:30 AM, the DON revealed she did not know that the care plan was updated in June for the staff to assist him with all meals or the care plan updated in August for him to be up in the wheelchair for all meals. She revealed Resident #13 has a history of wanting to lie down in bed and eat. That's his preference. SA asked the DON why she thought the care plan was put in on [DATE]. The DON revealed I didn't put it in, and I wasn't aware of that care plan or a choking incident. The DON stated, I wasn't aware of this incident until it was brought to my attention yesterday. I can't review every piece of paper that comes through. She revealed she is usually informed of any changes during the stand-up meeting each morning and revealed I do not know how the incident in June and August was missed, she confirmed I guess it was a breakdown in communication. She stated that for the incident on [DATE], the nurse let me know that night that she thought he was having a seizure and revealed she did not instruct the night shift staff to start an investigation because I thought it was a seizure. The DON revealed the staff called her back that night and said the resident was being admitted and had to be intubated. She revealed that they did not have stand-up the next morning. She stated, I can not remember why we didn't have it, but I was informed around one or one-thirty that day when we were having a party, she revealed a staff member said they had called over to the ER and had been told that he had something in his throat when they tried to intubate him. She stated, that's when we called over and got the medical records. She stated at that time they had started an investigation, but she still wasn't aware of the June and August incidents of choking until the State Agency (SA) had told her they had discovered documentation of choking in the medical records and nurses' notes. The DON confirmed that she didn't thoroughly investigate the choking because she thought it was a seizure. The DON confirmed she did instruct the staff to update the Resident's care plan on [DATE] for the CNA to Chop the meat. She revealed when it is in the care plan it pulls to the CNA's Kardex. She confirmed it was not in the care plan prior to the incident on [DATE] and it should have been. She confirmed that the CNAs would not have any way of knowing how to chop the meats until they corrected it on [DATE]. An interview on [DATE] at 10:40 AM the ADON revealed she did an in-service on [DATE] for the CNAs and nursing staff regarding Chopped meats. She confirmed the in-service was not attended by all nursing staff including CNA #2 and CNA #6. She revealed that the 7 p.m.-7 a.m. shift did not get the in-service on chopping meats because the meal trays are sent out on the day shift not the night shift. She confirmed that she did not demonstrate how to chop the meat to the in-service staff. Record review of the Diet requisition form Diet change dated [DATE] revealed Resident #13 was changed to a Mechanical soft chopped meat texture diet. Record review Meal ticket dated [DATE] at 2:34 PM diet order was changed to Chopped Meats; Knife and resident was served whole meats with a knife to cut. Record review of Resident #13's meal ticket, dated [DATE], all meals CCD-Mechanical Soft. Review of the Dinner meal ticket revealed- Ground Italian Sausage, brown gravy, parmesan noodles, broccoli florets chopped and sliced pears. The same meal was served on [DATE] the evening that the resident choked. Record review of the dinner meal ticket revealed, Italian Sausage, Parmesan noodles, Broccoli florets, sliced pears. Record review of Progress notes dated [DATE] at 18:20 PM, stated, Resident noted with choking episode this shift at dinner time. LPN reporting that the resident had gotten choked on a piece of meat off his dinner tray. LPN assist resident with dislodging piece of meat. Resident's color returning to normal with O2 (oxygen) saturation of 97% on RA (room air). Resident continued. to be noted with a cough. Record review of Progress Note dated [DATE] at 13:48 PM stated, It was reported to ST (Speech Therapy) that the pt got choked while eating meat the previous day. Also nurse reports pt had difficulty while taking meds today. Record review of Progress Notes, dated [DATE] at 10:16 AM stated, Resident is to be gotten up for meals in W/C (wheelchair). The Facility submitted the following Removal Plan, on [DATE], alleging removal of the immediacy as of [DATE]. 1. On [DATE] at 3:00pm, the Minimum Date Set (MDS) Nurse audited diet orders for residents that require chop meats and ensured that it is on the Kardex and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the Kardex and Care Plan by the MDS Nurse. 2. On [DATE] at 3:00pm, Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. On [DATE] at 7:30 pm, Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. On [DATE] at 8:00 am, Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). 5. On [DATE] at 1:00pm, Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. On [DATE] at 8:00 am, Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. On [DATE] at 11:22 am, Medical Director gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. On [DATE] at 1:00pm, Minimum Date Set (MDS) Nurse updated diets for all residents in facility on Mechanical Soft diet on Kardex and Care Plan. 9. On [DATE] at 1:00pm, Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. On [DATE] at 5:00pm, Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist, and Medical Director. 11. On [DATE] at 4:00pm, Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from [DATE] to [DATE] to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on [DATE] at 10:00 am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective [DATE]. 13. The weekend Registered Nurse was in-serviced on [DATE] at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The Regional Clinical Services counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on [DATE] at 10:00 am. 15. The Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on [DATE] at 4:00pm. 16. All in-services that have been initiated will have 100% completion by [DATE]. NO employees will be allowed to work until in-serviced. The facility alleges that all corrective actions were completed as of [DATE] and the Immediate Jeopardy removed on [DATE]. 1. The State Agency (SA) validated through record review and interview on [DATE] at 9:12 AM with the Minimum Date Set (MDS) Nurse that the diet orders were audited for residents that require chop meats and ensured that it is on the Kardex and Care Plan. Results noted five residents on chopped meats and five corrections were made to pull to the Kardex and Care Plan by the MDS Nurse. 2. The SA validated on [DATE] at 9:24 AM through record review and interview that the Nurse Educator initiated an in-service to nursing staff to supervise residents who require a chopped diet. 3. The SA validated on [DATE] at 9:24 AM through interview and record review that the Staff Development Coordinator initiated an in-service to all staff on Abuse/Neglect, Vulnerable Adults Act and Resident Rights. 4. The SA validated on [DATE] at 9:27 AM through interview that the Nurse Educator initiated in-services with nursing staff on verify a meal ticket, identify diet textures, fluid consistencies, Choking/Relief of foreign body obstructing airway, Heimlich Maneuver Competency, Crash Carts (location and how they are stocked). Record review of these in-services were validated by the SA. 5. The SA validated Speech Therapy evaluation was requested on residents that remain in facility on chopped meats by Administration and Medical Director. 6. The SA validated through interviews and record review on [DATE] that Speech Therapy evaluated four residents with chopped meats with no change noted in each residents Care Plan. Each resident was found to be safe on a chopped meat diet. Residents that are in hospital will be evaluated per Speech on return to facility. 7. The SA validated through interview and record review on [DATE] with the Medical Director that he gave orders to change all chopped meat diets to Mechanical Soft. Orders were changed on residents remaining in the facility with a chopped meat order, Responsible Parties of residents were notified, and dietary recommendations were turned into dietary department. 8. The SA validated through record review and interview on [DATE] with the Minimum Date Set (MDS) Nurse that updated diets for all residents in facility on Mechanical Soft diet are on Kardex and Care Plan. 9. The SA validated that the Nurse Educator initiated in-services to nursing staff to notify Director of Nurses of all transfers out of facility, giving a resident full assessment and documenting on each resident transferred out, making sure when passing trays, the meal ticket matches what is on the tray, chopped meat will no longer be provided it will be ground meat consistency (Mechanical Soft), and choking verses seizure (similarity and differences). 10. The SA validated through record review and interviews on [DATE] that an Emergency AD HOC Quality Assurance Meeting was held. Administrator in-serviced that paperwork on all transfers will be obtained and reviewed by the Interdisciplinary Team in morning stand up meeting. Those present were the Administrator, Director of Nurses, Assistant Social Services, Medical Records Clerk, Wound Nurse, Business office Managers, Housekeeping Supervisor, Nurse Educator, Social Services Director, Maintenance Director, Minimum Data Set (MDS) Nurse, Assistant Director of Nurses, Activity Director, Staff Development Coordinator, Human Resources, Respiratory Therapy, Regional Dietary Manager, Infection Preventionist and Medical Director. 11. The SA validated through interview on [DATE] with the Regional Clinical Services Nurse and Director of Nursing initiated an audit to review twenty-four-hour report from [DATE] to [DATE] to ensure no other incidents of choking or harm were documented and unreported to Administration. 12. The SA validated through record review and interview on [DATE] that the Regional Clinical Services Nurse in-serviced Administrator, Director of Nursing, and Assistant Director of Nursing on proper use of the twenty-four-hour report, Proper Reporting, and Proper Investigation on [DATE] at 10:00 am. The twenty-four-hour report will be printed each morning and taken to the daily stand-up meeting for review for all discipline documentation effective [DATE]. 13. The SA validated through record review and interview on [DATE] that the weekend Registered Nurse was in-serviced on [DATE] at 1:00pm to notify Director of Nurses with all transfers and incidents by the Nurse educator. 14. The SA validated through record review and interview on [DATE] with the Regional Clinical Services that she counseled the Administrator, Director or Nurses and Assistant Director of Nursing on investigation being timely and thorough on [DATE] at 10:00 am. 15. The SA validated through record review and interview on [DATE] that the Regional Clinical Services Nurse and Regional Case Mix Nurse in-serviced Administrator, Director of Nurses, Assistant Director of Nurses, Staff Development, Minimum Data Set (MDS) Nurses, Medical Records, Wound Nurse, Nurse Educator, Social Services Director, Assistant Social Services Director, Business Office Managers and Therapy on reviewing care plans in Care Plan Meeting on [DATE] at 4:00pm. 16. All in-services that have been initiated will have 100% completion by [DATE]. NO employees will be allowed to work until in-service is completed.

Based on staff interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect as evidenced by: (1) the facility's failure to identify a resident choked on [DATE]; failure to ensure the resident had supervision and was on a modified diet to prevent choking on [DATE]; and failure on [DATE] to supervise and modify diet which lead to the resident again choking and requiring Cardiopulmonary resuscitation (CPR) and hospitalization with a poor recovery prognosis. Resident #13. (2) the facility's failure to ensure a resident was free from verbal abuse as evidenced by a Certified Nursing Assistant (CNA) threatening to hit a resident for Resident #46 for two (2) of three (3) allegations of abuse and neglect reviewed. The facility neglected to identify or investigate the choking incident on [DATE] with required hospitalization for three (3) days and removal of a food bolus from his oropharynx and failed to have knowledge of the [DATE] choking incident that required the Heimlich maneuver to remove the food bolus from his oropharynx in the facility. This neglect resulted in the resident not receiving services to possibly prevent choking episodes. The resident's diet was changed on [DATE] to Consistent Carbohydrate Diet (CCD) mechanical soft. The Administrator had the resident's diet changed on [DATE] to CCD with chopped meats and the Certified Nursing Assistants (CNA)were to chop the resident's meat when the tray was served. The meal tickets were never changed to include the CNA to chop meats. On [DATE] in the evening, Resident #13 was served an Italian Sausage link that was five (5) to six (6) ,d+[DATE] inch chunks of meat and the resident was found in his bed, unable to breath and without a pulse or respirations. Cardiopulmonary Resuscitation (CPR) was performed for over ten (10) minutes and was not successful. Resident #13 was transported to the local hospital where he remains on life support. The facility's negligence to identify the choking incidents and to ensure that staff were aware of the diet needs of Resident #13 and serve the correct diet order to a resident with a known history of choking in the facility and dysphagia resulted in Resident #13 choking on [DATE] and required life saving measures and remained in the hospital on the ventilator at the time of the survey. This negligence resulted in harm for Resident #13 and placed other residents at risk in a situation that was likely to cause serious harm, injury, impairment or death. The situation was identified as an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when the first choking episode occurred and the facility failed to identify the event as choking. On [DATE] at 3:35 PM, the State Agency notified the facility's Administrator of the IJ and SQC and provided the Administrator with the IJ templates. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged all corrective actions were completed to remove the IJ on [DATE], and the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE], prior to exit and the scope and severity for F600 was lowered to an E, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Resident #13 Record review of the facility policy titled, Abuse Prohibition Policy with a revision date of [DATE] revealed, INTENT: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. POLICY: .2 .The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness Record review revealed a facility-reportable incident (FRI) that had occurred on [DATE] at 7:42 PM, when Resident #13 was noted to be having an active seizure while eating supper in bed. A record review of the Unusual Incident .Staff reported at the supper time, resident was asleep and did not want supper. Night shift Certified Nursing Assistant (CNA) #6 reported that she had assisted the resident to the restroom, and he was eating his supper, while she was caring for roommate. She heard (Resident #13) making a noise, and he was found actively having a seizure. The nurse was called to the room and life-saving measures were began by nursing staff ending in Cardiopulmonary Resuscitation (CPR). The resident was transferred to the hospital. Staff called to check on resident condition on [DATE] and was informed that a piece of sausage was extracted from the resident's oropharynx prior to resident being intubated. Medical records were obtained from (hospital) on [DATE] and received at 2:33 PM. Resident was intubated and noted to have Pneumonitis on [DATE]. After investigation, resident had a witnessed seizure causing aspiration of food content. I cannot substantiate abuse or neglect. This investigation was not dated but signed by the Administrator. Record review of Progress Notes, dated [DATE] at 19:42 (7:42 PM) revealed, Nurse was alerted by CNA that I was needed in resident's room. Upon arriving in room resident appeared to be having seizure activity. Pulse was faint and respirations noted. Resident had foamy secretions coming from mouth. Resident was pale in color . CNA told this nurse that prior to her alerting me he had been eating . This nurse performed back thrust times 5 and was in process of performing ABD (abdominal) thrust when other help arrived. Thrust was ineffective. Nurse left room and got crash cart and upon returning CPR was in process related to no pulse or respirations. Progress note for [DATE] at 19:45 (7:45 PM) Nurse observed resident unresponsive, pale and foaming at the mouth. Nurse called 911 and returned to aid with chest compression until EMS arrived. Record review of the local hospital emergency room report dated [DATE] stated, History of Present Illness .Per ambulance run report: Patient was found lying supine in bed upon arrival; nursing home staff stated that the patient was found unresponsive and cyanotic immediately after mealtime. Per ED (Emergency Department) sign out: Patient was exhibiting agonal breathing; a piece of sausage was extracted from his oropharynx prior to intubation . Problem List Plan: . Respiratory: Patient ' s acidosis and elevated lactate is likely attributed to airway obstruction caused by food getting stuck in his oropharynx; although there is clinical and radiographic evidence concerning for potential aspiration pneumonia .Infectious Disease: Radiographic and clinical suspicion for aspiration pneumonia . Feeding: Feeding tube inserted .CPR Exam: Narrative: .Respiratory: Decreased air entry throughout, stridorous respirations, significant accessory muscle use, saturating 49% on nonrebreather .On arrival, it immediately became apparent that the patient was in profound respiratory distress and needed emergent airway management. During the intubation, we visualized a very large piece of food obstructing the patient's airway, using forceps, and removed the foreign body. After the patient was intubated and sedated and placed on the ventilator, his vital signs normalized . An interview on [DATE] at 12:50 PM, CNA # 2 revealed on [DATE] she was passing the dinner trays and went into Resident #13's room and he was asleep, which is not uncommon for him, she revealed a lot of times he would wake up later and eat. She stated she tried to wake him, and he said he wasn't hungry and covered his head up. She sat the tray down on his side table and never uncovered it. She stated when she came back to work the next day, she found out that Resident #13 had choked. We were told to make sure we chopped his meats from now on. She confirmed she had never been in-serviced on how to chop the resident's meats before and wasn't aware that he was supposed to have his meats chopped because the diet ticket never said to chop his meats. An interview on [DATE] at 1:40 PM, with CNA #7 revealed the resident is a heavy eater and snacks in his room all the time. She revealed the day before he choked on [DATE], he had a whole piece of chicken that was served on his meal tray. She revealed we never cut his meat up before and the resident can eat by himself, and we don't stay in the room with him while he is eating. An interview on [DATE] at 8:10 AM, CNA #8 revealed she was never aware that the resident required his meats to be chopped before he choked on [DATE]. She revealed we were told after he choked that we needed to make sure and chop his meats, but not before. An interview on [DATE] at 8:25 AM with the dietary management group Account Manager revealed she has been at the facility for about two months and stated that when she started, she was told anyone with a chopped meats diet we were to put a whole piece of meat on the plate and put a knife on the tray so that the CNA could cut up the meat. She revealed this was the only place she had ever worked that I had heard that a CNA would cut the meat up. She stated on [DATE] she was in the kitchen but didn't cook the dinner meal but did observe the meal which consisted of Italian sausage that was cut into about one (1) to one and one-half (1 ,d+[DATE]) inch chunks and each resident got about three or four chunks of the meat on their tray. An interview on [DATE] at 8:50 AM with CNA #6 revealed that she was working the night of [DATE] and went into Resident #13's room at about 7:15 PM to get his vital signs. She stated he was asleep, and she woke him up and took his vital signs and temperature. The resident said he had to go to the bathroom, and he was hungry. I assisted him to the bathroom and then set up his tray which consisted of noodles, round Polish sausage there were about four large round pieces about ,d+[DATE] inch to one inch long on his tray, and broccoli florets. She revealed she did not cut the sausage up because she was not aware that he required his meat to be chopped or cut. She revealed I went and started getting his roommate's vital signs and then she heard Resident #13 make a sound I never had heard before, she stated she thought he was having a seizure because he had fallen back on his bedrail and was foaming out of the mouth. I went for help immediately. She revealed on his plate he had eaten all the sausages and maybe one of the broccoli florets. She stated that after this incident we were in-serviced to make sure to look on the meal ticket and that CNAs were responsible for chopping meat for residents requiring chopped meats. We were also in-serviced on neglect and abuse. She confirmed before the choking incident they were not told to cut the residents' meats up. She stated she had worked here for about a year and had never been told to chop his meats before and hadn't seen his meats chopped up. In an interview on [DATE] at 9:30 AM, the Administrator (ADM) revealed Speech Therapy had ordered a chopped meats diet in August because the resident had a choking episode. She revealed the Dietary Director of Operations told her they were not able to do a chopped meats diet. She revealed we immediately in-serviced the staff that the kitchen would send out the appropriate knife and they would have to chop the meats. She stated, I did not feel comfortable with my staff cutting the meats, but I was told by the Dietary Director of Operations that it was a facility policy but since then I found out that was not true. She confirmed that she found out that was not true through the Corporate Chief Operating Officer (COO) and stated, I didn't say anything to the Dietary Director of Operations after that because that's a corporate-level issue and I was letting them handle it. She stated, I could make it happen today to stop all chop meats and just do a Mechanical soft. I haven't done it yet because Corporate had been working with the dietary management company about the issue. She revealed that since the incident happened on [DATE] with Resident #13 the aides are still chopping meat for the residents and stated that we keep a list of residents who require chopped meats at the nurse's station. The Administrator confirmed when she found out on [DATE] that the resident had choked, she had not done anything different with the chopped meat diets because corporate was working on that. An interview on [DATE] at 10:05 AM with the Director of Operations (DO) for the dietary services management group revealed that dietary services has three diets which are Regular, Mechanical Soft, and Pureed. He stated that Resident #13 was put on a chopped meat diet on [DATE], because he had a choking episode. He confirmed that he had asked the Administrator for a diet clarification because dietary does not historically do chopped meats, but could do mechanical soft, and he was told by the Administrator to send out a knife for the residents who were on a chopped meat diet and the aides would chop the meats. He confirmed that this occurred on the Thursday before Labor Day, which would have been [DATE]. The Director of Operations for Dietary revealed he is over 23 buildings, and this is the only building where they are doing chopped meats and requiring aides to chop the meat when it gets to the resident. He stated, I don't like doing that, but I couldn't get the Administrator to understand that chopped meats is a mechanical soft diet, I just needed them to get the order clarified. An interview on [DATE] at 12:55 PM with the Nurse Consultant, Director of Nurses (DON), and Administrator revealed they were not aware of the choking episode on [DATE]. The DON and Nurse Consultant revealed they were not aware of a choking episode on [DATE]. The Administrator revealed she was aware of the [DATE] choking episode and had a conversation with the Dietary because Speech Therapy had evaluated Resident #13 and requested a chopped meat diet. An interview on [DATE] at 2:05 PM, with CNA #7 revealed she never saw on the electronic charting guide for Resident #13 that the CNA was to chop meats. She revealed, our tablets are how we know how to chart for the residents and what they are supposed to get. An interview on [DATE] at 2:15 PM with CNA #4 revealed, I've never seen chopped meats listed on the tablets that we use to document. An interview on [DATE] at 2:25 PM, the Speech Therapist (ST) confirmed Resident #13 was on caseload for dysphagia beginning [DATE] through [DATE] and then again up until he was discharged to the hospital on [DATE]. She revealed the recommendations were for him to be supervised for meals. He was at risk of aspiration because he wanted to lie down and eat. She revealed she would always caution Resident #13 about sitting up and eating and not lying down to eat. An interview on [DATE] at 2:35 PM, the Minimum Data Set (MDS) nurse updated the care plan on [DATE] to be up in w/c for all meals and stated that she put it in there when he had his quarterly MDS. She revealed I think we also may have talked about it in the morning meeting, but I'm not sure. An interview on [DATE] at 2:45 PM, the Medical Records Nurse revealed that when a resident comes back from the hospital the hospital directly uploads any paperwork into our system. She revealed the hospital will notify the Social Worker (SW) that they are uploading paperwork from the residents' hospital stay. She confirmed we usually review the paperwork in our standup meeting the next day or our clinical standards meeting on Friday. She confirmed for those meetings the Director of Nursing (DON), Assistant Director of Nursing (ADON), MDS nurse, Treatment Nurse, Social Worker, and Administrator are in attendance. She stated, I don't know what happened in June when Resident #13 went out to the hospital and when he returned the discharge paperwork revealed he had choked and confirmed that she had apparently overlooked it. A phone interview on [DATE] at 3:30 PM with the Medical Director revealed, As far as I know he never had any seizures. He stated he had access to the hospital records and according to the hospital records they are currently treating Resident #13 for pneumonia and encephalopathy and the family is there, and they are talking about putting him on hospice because the prognosis is very poor. An interview on [DATE] at 4:00 PM, Registered Nurse (RN) #2 revealed on [DATE] was the Nurse Supervisor; she stated the floor nurse hollered for me and said she had done the Heimlich maneuver on Resident #13 and was able to get the food expelled. She revealed we called the doctor to see if there was anything he wanted us to do, and she revealed he wanted us to watch for any signs or symptoms of possible aspiration. She stated they put in a diet order change the next day for chopped meats and confirmed the order put in for care plans for him to be set up in the wheelchair was due to the choking episode on [DATE]. She revealed she was unaware of the choking episode for Resident #13 in June and stated we have a daily stand-up meeting where all disciplines attend including the Administrator, DON, and ADON. She confirmed I'm not sure if it was discussed in the morning stand-up meeting or the clinical standards meeting about him choking on [DATE] but all the nursing knew about it and his care plan to be up in his wheelchair for all meals. An interview on [DATE] at 4:10 PM, with the Administrator revealed for the incident on [DATE] she was not made aware that Resident #13 was eating dinner until the next day on [DATE] around lunch time. She confirmed the nurse told her that he had a seizure and they had to do CPR and he was sent to the hospital. She had seen the hospital paperwork on [DATE] that revealed he had the sausage in his oropharynx and revealed for the [DATE]th incident the staff nurses just reported that he got strangled on his food and that's when he got the order for speech therapy to be evaluated. She confirmed she wasn't aware that Resident #13 required the Heimlich maneuver at that time. An interview at the same time with the DON revealed for the [DATE] incident she was made aware that the resident had trouble with taking his medicines and wasn't made aware of him choking. She revealed she is going to start going back and reading the nurse's notes each day so she will know what is going on. She revealed it usually will come out on the 24-hour nurses report and we will discuss it in the morning meeting. The DON and Administrator both revealed they were not sure how the choking episodes got missed. The DON confirmed after the [DATE] incident she instructed Resident #13's care plan to be updated to make sure CNA to chop meats was reflected on his meal tickets and that she was the one that put it on his [DATE] meal ticket for CNA to chop meats, and confirmed that it was not on there for the CNA to see that day. She confirmed it was not on the care plan before [DATE] and it should have been. She confirmed again that she was not aware of Resident #13 having a choking episode in June or August and that she wasn't aware that he had choked on [DATE] until the afternoon on [DATE]. A phone interview on [DATE] at 4:25 PM, Licensed Practical Nurse (LPN) #5 confirmed she was working the night shift on [DATE] and that the CNA came and said she needed a nurse in Resident #13's room. She revealed the CNA said she thought he was having a seizure because he had foam coming out of his mouth. I took off to the room and when I entered it appeared that Resident #13 was having seizure activity. I put him in a recovery position on the right side and the CNA said he had been sitting up eating so I thought at that time that he was probably choking. She confirmed I did five thrusts to the back, and when I went to turn him over to do the abdominal thrust other help had arrived in the room and he was not breathing. I went and got the crash cart at that time and when I returned to the room CPR was in process. She revealed when EMS arrived, I told them he was having seizure-like activity. She revealed I had never worked with Resident #13 but had heard reports that he had choked before. She confirmed another nurse was on the phone with the DON at that time. And had notified her. I knew that he was on a chopped meats diet but there was no residue of any meat on the plate at that time, just some broccoli. An interview on [DATE] at 8:30 AM, the DON stated regarding the incident on [DATE], the nurse let me know that night that she thought he was having a seizure and revealed she did not instruct the night shift staff to start an investigation because she thought it was a seizure. She revealed that they didn't have stand-up the next morning, I can't remember why we didn't have it, but I was informed around one or one-thirty that day when we were having a party, when a staff member said they had called over to the ER and had been told that he had something in his throat when they tried to intubate him. She stated that's when we called over and got the medical records. She stated at that time they had started an investigation, but she still wasn't aware of the June and August incidents of choking until the SA told me on [DATE]that it was located in the medical records and nurses' notes. The DON revealed the staff called her back that night and said the resident was being admitted and had to be intubated. The DON confirmed that she didn't thoroughly investigate the choking because I thought it was a seizure. She revealed that any resident sent out to the hospital, the staff will have to notify the DON or the Administrator right away. An interview on [DATE] at 10:00 AM, the Social Worker stated she was aware that he had choking episodes before the recent one on [DATE] but could not remember specific dates. She confirmed in the morning meeting we discuss any major issues and choking is an important issue. She revealed the morning meeting is made up of all department heads, which also includes the Administrator and DON. An interview on [DATE] at 10:40 AM, the ADON revealed she did an in-service on [DATE] for the CNAs and nursing staff regarding chopped meats. She confirmed the in-service was not attended by all nursing staff including CNA #2 and CNA #6. She revealed that the 7 PM -7 AM shift did not get in-serviced on chopping meats because the meal trays are sent out on the day shift not the night shift. She confirmed that she did not demonstrate how to chop the meat to the in-service staff and that not all staff were in-serviced. An interview on [DATE] at 10:50 AM, the Administrator revealed the Registered Dietitian (RD) consult record is made up by the nursing department and given to the RD each week when she comes. She revealed the residents on the consult record and the residents that have had any significant changes are usually listed on the record to be seen that week. She confirmed that Resident #13 had never been put on the list for the RD to see after the choking episodes. Record review of Resident #13's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Transient Cerebral Ischemic Attack, Dysphagia, Altered Mental Status, and Unspecified Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had a severe cognitive impairment. The assessment further indicated under Section GG that Resident #13 required for eating, supervision, or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. The assessment further indicated under Section K that Resident #13 had coughing or choking during meals or when swallowing medication and complaints of difficulty or pain with swallowing. Record review of the local hospital emergency room Report dated [DATE] revealed chief complaint: Altered Mental Status. Rehab facility was contacted for further information regarding patient's presentation, and they reported that patient had abnormal moaning and jerking-like motions, and that staff had concerns for new onset seizure-like activity. Per chart review, patient has no prior history of seizures but does have a history of Cerebral Vascular Accident (CVA) involving left middle cerebral artery. At the time of my exam, it was noted that a patient had a golf ball sized food bolus extracted from posterior oropharynx. A record review of Progress notes dated [DATE] by the Medical Records Nurse, Note Text: Resident discussed in clinical standards, return from hospital on [DATE], continues all meds as ordered, new med of levetiracetam 500 mg bid for seizures, alert with periods of confusion, up with assist, CCD diet, will monitor. Record review of Progress notes dated [DATE] at 18:20 PM, stated, Resident noted with choking episode this shift at dinner time. LPN reporting that the resident had gotten choked on a piece of meat off his dinner tray. LPN assist resident with dislodging piece of meat. Resident's color returning to normal with O2 (oxygen) saturation of 97% on RA (room air). Resident cont. (continues) to be noted with a cough. Record review of Progress Note dated [DATE] at 13:48 PM stated, It was reported to ST (Speech Therapy) that the pt got choked while eating meat the previous day. Also nurse reports pt had difficulty while taking meds today. Record review of Progress Notes, dated [DATE] at 10:16 AM stated, Resident is to be gotten up for meals in W/C (wheelchair). Record review of the Diet Requisition Form diet change dated [DATE] revealed Resident #13 was changed to a Mechanical soft chopped meat texture diet. Record review meal ticket dated [DATE] at 2:34 PM diet order was changed to Chopped Meats; Knife and resident was served whole meats with a knife to cut. Record review of the Order Summary Report Active Orders as of [DATE] revealed an order dated [DATE], CCD Diet, Chopped Meat texture, thin consistency. Record review of Resident #13's meal ticket dated [DATE] all meals CCD-Mechanical Soft. Review of the Dinner meal ticket revealed- Ground Italian Sausage, brown gravy, parmesan noodles, broccoli florets chopped and sliced pears. The same meal was served on [DATE] the evening that the resident choked, and review of the dinner meal ticket revealed, Italian Sausage, Parmesan noodles, Broccoli florets, sliced pears . knife .CNA will cut meat Resident #46 An interview with the Administrator on [DATE] at 10:55 AM, revealed on [DATE], there was a witnessed verbal abuse incident of Resident #46 by Certified Nursing Assistant (CNA) #1. She revealed CNA #1 admitted that she threatened to hit Resident #46 and she was terminated for verbal abuse. The Administrator revealed this incident was reported to the State Agency (SA) and other entities and an investigation was completed. During a phone interview on [DATE] at 8:05 AM, Resident #46's brother, his Resident Representative (RR), revealed the facility notified him that CNA #1 threatened to hit his brother and that she was terminated for this. During a phone interview on [DATE] at 4:10 PM, CNA #1 revealed Resident #46 was upset and angry and was swinging his arms and trying to hit her. She stated she did not threaten the resident she was going to hit him, but told him, Don't hit people. They are going to want to hit you back. She stated Licensed Practical Nurse (LPN) #1 yelled at her to not talk to residents that way and she then told LPN #1 that if someone hit you, you would want to hit them back. When asked about her written statement, Don't hit me if you hit me I'm going to hit you back, she stated she did write that in her statement and that was what happened, but she did not mean she was going to hit him, she just wanted him to know that he could get hit back if he hit another resident or any other person. When asked if the statement she wrote at the time of the incident was accurate, she confirmed that what she wrote was what happened. She stated, It's fine, I just want to get this over with. She stated she was fired because of this incident. She verified she had been in-serviced on abuse and neglect. During a phone interview on [DATE] at 4:30 PM, LPN #1 revealed she was working on the medication cart at the nurse's station, and she saw CNA #1 pushing Resident #46 in his wheelchair and she heard CNA #1 tell the resident, If you hit me, I am going to hit your ass back. She said she confronted the CNA and told her she could not talk to the resident that way and she told me that if nobody does anything about him hitting, then I can tell him that. She stated, I was actually offended hearing her talk to the resident that way and any other resident or family overhearing this would also have been offended. She confirmed this was abusive towards the resident and she reported it immediately. On [DATE] at 5:00 PM, during a phone interview, CNA #2 revealed she was a Nurse's Aide when this incident occurred, and since she was not certified, she was working with CNA #1. She stated the resident was in his wheelchair and was trying to get out of the chair, so CNA #1 went to him to take him to the nurse's station. She stated Resident #46 was angry and swung his arms and CNA #1 told him that if he hit her, she was going to hit him back. She stated she told CNA #1 to calm down and that it was not the resident's fault, but CNA #1 responded with Resident #46 should not hit people or he would get hit back. CNA #2 stated LPN #1 was at the nurse's station and heard what was said and reported the incident. She stated she gave her statement during the investigation. During an interview with the Director of Nursing (DON) on [DATE] at 9:50 AM, it was revealed that an allegation of verbal abuse of Resident #46 by CNA #1 was reported. She stated this was reported and CNA #1 was told to leave the facility immediately and an investigation was done. She stated CNA #1 was terminated due to her confession and the results of the investigation. The DON confirmed the facility failed to ensure a resident was free from verbal abuse by a staff member. An interview with the Administrator on [DATE] at 9:51 AM, revealed that CNA #1 admitted that she told Resident #46 that if he hit her, she would hit him back and she also wrote a statement that verified what occurred during this incident. She stated when this allegation of abuse was made, the facility reported this to the State Agency, Attorney General's office, and to the local police department and CNA #1 was suspended and then terminated. The Administrator confirmed the facility failed to ensure that Resident #46 was free from verbal abuse by a staff member and abuse towards any resident was not acceptable. Record review of CNA #1's statement dated [DATE] revealed, Don't hit me if you hit me, I'm going to hit you back. He was swinging and throwing things before this and both nurses stood and watched. Record review of the witness statement of LPN #1 dated [DATE], revealed, At approximately 10:05 AM this nurse was standing at the med cart that was on A-Wing at the nurse's desk and observed (proper name removed) CNA #1 propelling (proper name removed) Resident #46 to nurse's desk and heard CNA tell resident, I [TRUNCATED]

Based on record review, staff interview and facility policy/procedure review, the facility failed to ensure that one (1) of eight (8) residents reviewed (Resident #1) received the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care as evidenced on [DATE]. Resident #1 was found unresponsive; Cardiopulmonary Resuscitation (CPR) was initiated by Registered Nurse (RN) supervisor and continued for approximately five (5) minutes. The Registered Nurse supervisor failed to activate Emergency Medical Services (EMS) and Resident #1 expired. Resident #1 was admitted to the facility on [DATE] and her Responsible Party (RP) completed the Advanced Directives and elected Full Code for her on admission. It was determined that an Immediate Jeopardy existed in Professional Standards due to RN #1 not activating EMS after finding Resident #1 unresponsive and confirming she was a Full Code was identified and reported to the facility Administrator and Director of Nurses on [DATE] at 4:55 p.m. The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 4:30 p.m. Verification of the facility's corrective actions was conducted on [DATE] beginning at 4:30 p.m. Based on verification of the facility's corrective actions that were verified by surveyor through staff interviews and documented in-services, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] from a "J " to a "D" level, which constituted no actual harm with potential for more than minimal harm. The facility will remain out of substantial compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings include: Record review of RN #1's personnel file revealed she had signed and dated the facility's "CPR AWARENESS POLICY" on [DATE]. Record review of Resident #1's medical record revealed that Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On [DATE], Resident #1 and her Responsible Party (RP) signed the facility's "RESIDENT/FAMILY CONSENT FOR CARDIOPULMONARY RESUSCITATION" form. There is a check mark beside the comment "I understand that CPR constitutes an extraordinary measure and SHOULD be done on (Resident #1's name)". Review of the MD orders dated [DATE] reveal "CODE STATUS FULL CODE". review of the resident's medical record revealed [REDACTED]. The "FACE SHEET" has in the " ADDITIONAL INFORMATION" "Code Status FULL CODE". Nurse ' s note dated [DATE] 11:17 p.m., revealed "Certified Nurse Aide (CNA) #1 reported resident not breathing at 10:00 p.m. This nurse responded immediately and found resident with 0 respirations, eyes open, pupils fixed and dilated, Unable to obtain a pulse. CPR initiated, after 1 round of CPR still no pulse, no respirations and no blood pressure, resident eyes glazed over and skin is cold. CPR stopped at 10:30 p.m. Coroner notified at 10:35 p.m., family contacted at 10:45 after several unsuccessful attempts. Tried to contact (MD name) via pager, left message for Dr to call facility. Funeral home contacted." This note was signed by RN #1. LPN is seen after her name because of her recently becoming a RN and the computer has not been changed. Nurse ' s note dated [DATE] at 3:27 a.m. revealed "(Name of funeral home) arrived at 1:20 a.m. to pick up resident. The funeral home director talked to the resident's son and daughter in law for a few minutes, who were in the resident's room waiting on him. The family left, and myself along with the CNA's helped to place resident on stretcher. Resident left at approximately 1:30 a.m. with (Name of funeral home) director". Review of Resident #1's Death Certificate revealed the primary reason for expiration was listed as "[MEDICAL CONDITION]" and secondary was listed as " [MEDICAL CONDITION]". Staff interview on [DATE] at 4:10 p.m. with RN #1 revealed, "It was around 10:30 p.m. I was charting. I heard a CNA say 'she doesn't look right' and another say 'she's not breathing'. It was CNA #1 that said 'she didn't look right'. (Name of LPN #1) and I were called into her (Resident #1) room. (Resident #1) eyes were open, glazed over, 0 response to light from pupils, her skin was bluish gray, 0 pulse, 0 respirations, her skin was ice cold. She was not a Do Not Resuscitate (DNR). I pulled her chart to check code status. I couldn't get the crash cart doors to open. I just grabbed the ambu bag. I was hanging on the side in a plastic bag. I didn't call 911; I was trying to get back to the patient. I didn't have anyone else call 911. (LPN #1) did respirations with (the) ambu bag. I did chest compressions. The other LPN's from A side came to help. I had called over the intercom for help. I asked them what I needed to do. I've never been in a code or done CPR. (LPN #3) said they just usually call the coroner. (LPN #3) didn't know the code status. She didn't know (Resident #1) was a full code. We did CPR for five (5) minutes total. I called the coroner. We had stopped CPR. There were still no respirations or pulse. Me and (LPN #1) tried to find the procedure on what to do when someone expires. We couldn't find it. I was just trying to do CPR. I know I should have called 911, I know that. I honestly did not know what to do. I didn't call the doctor either. I (have) been a RN since [DATE]. I was a LPN since [DATE]. I worked there part time as a LPN. I started back a RN [DATE]. " Staff interview on [DATE] at 5:10 p.m. with CNA #1 revealed, "Me and (CNA #2) started rounds about 9:30. When we got to (Resident #1), we both went in. I got halfway in the room and said to CNA #2 'stop, look at her, she's not breathing.' I went over to her bed. Her pupils were set, eyes open, mouth open, skin pale, fingers and toes were blue. I touched her when (RN #1) came in, she was cold. I hollered out for help. (RN #1) was the first to come in. (RN#1 and LPN #1) came in. They tried to get her to respond. (RN #1) went to check her chart to see if she was a DNR or full code. (LPN#1) started CPR. She was doing chest compressions. I was checking for a pulse. (RN #1) came back and helped (LPN #1) for a few minutes. I never saw an ambu bag. (LPN #1) was doing open mouth breaths. (RN #1) was just in and out of the room. She was making calls trying to get the Director of Nurses (DON) and Administrator. No one even mentioned calling 911. (RN #1) said to stop CPR, It was about 30 minutes they did CPR then stopped. (RN #1) made the call to stop CPR. (RN #1) called the coroner and family." Staff interview with CNA #2 on [DATE] at 8:30 a.m. revealed, "I was doing last rounds. I got to her around 10:20 p.m. (CNA #1) noted when we walked in that she wasn't breathing. She said something ' s wrong with her, she's not breathing. We called her name; it looked like she took a breath and then nothing. Her eyes and mouth were open, she was pale. Her skin was cold. We hollered out for the nurse. We called out (RN #1)'s name. She was the RN supervisor that night. Before we went into (Resident #1)'s room, we had seen (RN #1) at the nurses desk. (Resident #1)'s room was across from the nurses ' station. (RN #1) came in, we tried to get a pulse, a B/P (blood pressure), there was nothing. I saw (RN #1) do chest compressions. I did not count how many. I didn't notice if (RN #1) put anything on (Resident #1)'s face or do mouth to mouth breathing. When me and (CNA #1) were trying to get respirations, pulse and B/P, (RN #1) left the room to call for other nurses; I heard that over the intercom. I didn't see any nurses come into (Resident #1)'s room but (RN #1). (RN #1) came back into the room about five (5) minutes after she had left. When (RN #1) went to call the coroner, I saw her holding an ambu bag. I did not notice if she used it on Resident #1. I did not know (Resident #1)'s code status." Staff interview with LPN #1 on [DATE] at 9:00 a.m. revealed, "I saw (Resident #1) at 9:00 p.m. or a little after to give her the bedtime meds. She was fine. She took her finger and threw each pill on the floor. That wasn't unusual for her to do that. She didn't say anything. She had not been here long. The previous night, she had been vomiting with diarrhea. I had gotten an order to do a flu test, Complete Blood Count (CBC) and meds ordered Immodium and [MEDICATION NAME]. One of the pills she threw out was an Immodium. She had one episode of diarrhea on my shift the night she died . CNA's were doing rounds; it was close to 10:00 p.m. I heard (CNA #1) yell for (RN #1) to come check Resident #1. I think RN #1 was at the nurses ' station. (Resident #1)'s room was close to the station. I went to her room also. (Resident #1) was on the bed, very pale, eyes open, mouth open, pupils fixed and dilated and glazed over. She was real pale with a blue tint. Her skin was very cold. RN #1 was on the right side of the bed. We assessed her. I was checking for a pulse and respirations. (RN #1) was also assessing her. I did not know her code status at that time. The code status is found at the front of a resident chart. A green sheet states Full Code, a red one says DNR. Me, (RN #1), (CNA #1) and (CNA #2) were the only four (4) in the room. RN #1 ran out to check her chart and ran back in and said 'She's a full code.' RN #1 started chest compressions. I can't recall when the ambu bag appeared but RN #1 went and got one. About 5- 10 minutes after doing chest compressions and respirations with the ambu bag, RN #1 said 'I've got to call (DON and ADM)'. RN #1 had been in and out of the room several times in that ,[DATE] minute period. (CNA #1) was trying to help me with CPR, checking for a pulse. I don't know who all RN #1 called. I did not ask about her calling 911. She comes in and says, 'I've got to call the coroner and family.' The total time between beginning CPR and RN #1 saying she needed to call the coroner was ,[DATE] minutes. She said to stop CPR when she said she was going to call the coroner. I was still checking for a pulse about ,[DATE] minutes later, I stepped out of the room and the coroner was coming down the hall. He had been across the street when he got RN #1's phone call. I had stayed in the room, so I never knew who all she called until after the fact. About 10 minutes after coroner was here, I found out that RN #1 never called 911. I never left the residents room while this was going on. RN #1 was the RN supervisor; she was making a lot of phone calls so I thought she was also calling 911. I was following my RN supervisor ' s instructions." Staff interview with the Director of Nurses on [DATE] at 10:45 a.m. revealed, "On [DATE], RN #1 called me around 10:40 p.m., I missed that call. About 10:50 a.m., I checked my phone so I called her back. She said we had a resident pass and she told me who, I asked if (Resident #1) was a full code or DNR. She said she was a full code. I said 'so you initiated CPR and called EMS? ' . She said 'I initiated CPR but didn't call EMS.' She repeated that. She said she called the coroner. I said, '(RN #1), do you realize what you did? You stopped a code like you were the doctor.' She said, 'Oh, did I do something wrong?' I told her 'yes, we have to call 911. We let EMS come and take over.' She said the coroner was with her. She said what the primary (cause of death) was 1.[MEDICAL CONDITION] and 2. [MEDICAL CONDITION]. I called the ADM and told him what happened." Review of the American Heart Association's website revised 2013 revealed that the "CHAIN OF SURVIVAL"'s first step is "Immediate recognition of [MEDICAL CONDITION] and activation of the Emergency Response System". The second step is " Early Cardiopulmonary Resuscitation (CPR) with an emphasis on chest compressions". Review of the "MS Vulnerable Adult Act" revised ,[DATE] revealed the definition of neglect as "NEGLECT is clarified by inclusion of the reasonably prudent person standard, which is now used to determine what action is necessary by the caretaker, to maintain the vulnerable adult's mental and physical health. Again, only a single incident is necessary for a determination of neglect." Review of the facility's policy/procedure for "CPR AWARENESS POLICY " revised ,[DATE] revealed "It is the policy of our company that CPR will be initiated on all residents without DNR (Do Not Resuscitate) or Advanced Directives identified. If the resident has an order written [REDACTED]. If the resident and/or responsible party has determined that CPR should be performed, a green sheet will be placed in the resident's chart. The steps to take when a resident is found to be without pulse or respirations are as follows: Determine the Code Status Assess the Resident Call the code Initiate CPR Call 911 (Activate EMS) & the on-call physician The only time a nurse cannot initiate CPR or can cease performing CPR once initiated is when you have been directed to do so by a physician or when EMS arrives and takes over. There is no third option. There is never a situation in which a nurse can make the decision not to initiate CPR on a Full Code resident. NEVER! There is never a situation where a nurse can order CPR to be stopped once initiated. NEVER!" Review of the facility's policy/procedure for "FREEDOM FROM ABUSE OR NEGLECT" revised ,[DATE] revealed "It is the policy of this facility that each resident has the right to be free from mistreatment, neglect, abuse and misappropriation of property by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. DEFINITIONS: "ABUSE" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in coma, cause physical harm, or pain or mental anguish." It was determined that an Immediate Jeopardy existed due to RN #1's failure of not activating EMS after finding Resident #1 unresponsive and confirming she was a Full Code. It was determined that Substandard Quality of Care (SQC) and Immediate Jeopardy were identified and reported to the facility Administrator and Director of Nurses on [DATE] at 4:55 p.m. The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 4:30 p.m. ALLEGATION OF COMPLIANCE "On [DATE] at approximately 10:00 p.m. Certified Nursing Assistant (CNA) #1 and CNA #2 entered Resident #1's room and observed the resident to appear unresponsive. RN #1 put oxygen saturation meter on Resident #1's finger with no reading detected at approximately 10:00 p.m. RN #1 went to the nurses ' station and checked Resident #1's medical record to determine her code status at approximately 10:00 p.m. Finding that Resident #1 was a 'Full Code', RN #1 returned to Resident #1's room and initiated cardio [MEDICAL CONDITION] resuscitation (CPR). RN #1 performed CPR on Resident #1 with no results. LPN #1 took over CPR while RN #1 left the room and attempted to call the Director of Nursing (DON) between 10:00 p.m. and 10:30 p.m. RN #1 failed to follow the CPR Awareness Policy and activate Emergency Medical Services (EMS). After an undetermined amount of time, RN #1 re-entered Resident #1's room and instructed LPN #1 to stop CPR at approximately 10:30 p.m. RN #1 returned to the nurse's station and called the (county) County Coroner at approximately 10:35 p.m. and Resident #1's family at approximately 10:45 p.m., to notify them of Resident #1's passing. On [DATE] the (county) County Coroner arrived at approximately 10:45 p.m. and completed a Death Certificate listing the cause of death as 1. [MEDICAL CONDITION] 2. [MEDICAL CONDITION]. On [DATE] at approximately 10:57 p.m., RN #1 notified the DON of Resident #1's passing. The DON questioned RN #1 about Resident #1's code status and identified the fact that R #1 failed to call Emergency Medical Service (EMS) during the code process. On [DATE] at approximately 10:57 p.m. the DON immediately conducted re-education to the Nursing staff regarding what to do when a resident is found unresponsive and has a full code status. On [DATE] at approximately 100:00 p.m. the DON instructed RN #1 to complete her documentation of Resident #1's passing. On [DATE] at approximately 11:09 p.m., the DON contacted the Nursing Home Administrator (ADM) to notify him of RN #1's failure to call EMS during the code process. On [DATE] at approximately 11:09 p.m. the Director of Nursing notified the Administrator of Resident #1's passing and code status. In addition, the Director of Nurses identified the failure of RN #1 to notify Emergency Medical Services on [DATE] at approximately 10:57 p.m. An immediate investigation and corrective steps were implemented including immediate in-service of RN #1 and LPN #1 on the requirement to call EMS during a code by the Director of Nursing at approximately 11:00 p.m. on [DATE]. RN #1 documented the occurrences, and waited for Resident #1's family to arrive between 11:00 p.m. and 12:00 a.m. RN #1 accompanied the family to Resident #1's room. RN #1 waited for the funeral home to pick up Resident #1 at approximately 1:20 p.m., and clocked out at approximately 1:30 a.m. On [DATE], at approximately 7:00 a.m., the Staff Development Nurse (SDC) and Director of Nursing began re-in servicing of the facility staff including Licensed Nurses, CNAs, Therapy Staff, Housekeeping and Laundry Staff, Dietary Staff, Maintenance Staff and Department Heads related to what to do in the event a resident is observed unresponsive. Licensed Nursing Staff were re-in serviced regarding how to determine a code status, what to do if an RN Supervisor does not initiate CPR on a full code status resident, or stops CPR once CPR has been initiated. EMS must be notified and CPR can only be stopped by the order of a physician, or when EMS arrives in the facility and takes charge of the code. Staff was also re-in serviced on abuse and neglect, vulnerable adult, resident rights, and the CPR policy. At approximately 7:00 a.m., Re-in servicing was provided prior to nursing employees being allowed to work their assigned shift. In-services were completed on [DATE]. No staff member was allowed to work prior to re-education. On [DATE], at approximately 10:40 a.m., the Administrator Notified the Medical Director with an adhoc Quality Assurance meeting with the DON, SDC, and Clinical Services Coordinator conducted to review Resident #1's status including her being a full code and emergency medical services not being notified. Also included in the QA discussion were the corrective steps of: ? auditing active resident's code status alert sheet and code status consent form to ensure congruency; ? auditing of active resident's care plans to ensure accurate code status; ? reviewing active resident's code status with the resident, responsible party, and physicians; ? performing mock code drills each shift to include active nursing staff; and ? Auditing of licensed employees CPR. The DON/designee will conduct mock drills weekly for four weeks and monthly thereafter two months to maintain compliance. The DON will report findings to the Quality Assurance Committee for further recommendations. The DON is responsible for overall monitoring and ongoing compliance. " On [DATE], at approximately 11:00 a.m., a comprehensive audit of the eighty four (84) active resident's code status alert sheets, code status consent forms and care plans was completed by the MDS coordinators and Director of Nursing with no negative findings identified. On [DATE] at approximately 7:30 a.m. the staff development coordinator initiated an audit of licensed nursing staff's CPR certification to ensure direct care staff certifications were current; no negative findings were identified. On [DATE] at approximately 12:30 p.m., the Administrator interviewed RN #1 and suspended her pending the outcome of the investigation for not following the CPR Awareness Policy and activating EMS. On [DATE], LPN #1 was not scheduled to work and was informed by the Staff Development Coordinator that she could not return to work until she was interviewed by the Administrator. On [DATE], at approximately 12:15 p.m., LPN #1 was re-interviewed by the Administrator and suspended pending investigation to determine if she followed the CPR Awareness Policy. No additional disciplinary actions were taken against other employees. On [DATE], at approximately 2:50 p.m., the Director of Nurses initiated code drills which were conducted with ,[DATE] and ,[DATE] shifts. Staff responded appropriately. On [DATE], at approximately 11:08 p.m., the Director of Nurses conducted a mock code drill with the ,[DATE] staff, with staff responding appropriately. [DATE], at approx 3:48 p.m., the Mississippi State Department of Health, Licensure & Certification was notified by the Director of Nursing that on [DATE], at approximately 10:00 p.m., CPR was initiated on Resident #1 and RN Supervisor #1 stopped CPR without a physician's orders [REDACTED].#1's failure to follow facility policy related to full code status for Resident #1. On [DATE], at approximately 5:14 p.m., the Mississippi Attorney General's office was notified by the Administrator completing the on-line reporting form of the AG website. Verification of the Allegation of Compliance was confirmed on [DATE] by: 1. Review of the [DATE] comprehensive audit of active resident code status alert sheets, code status consent forms and care plans to ensure that all Active Resident charts had the correct "Code Status Alert" sheet, resident "Code Status Consent" forms were signed by the Resident or Responsible Party and that "Do Not Resuscitate" (DNR) care plans are on DNR Resident charts. 2. Review of the [DATE] audit of licensed nursing staffs CPR certification to assure that all Licensed Practical Nurses and Registered Nurses were CPR certified and Certifications were not out of date. 3. Review and verification of employee signatures of the [DATE]-[DATE] in-services of facility staff concerning what to do if a resident is observed unresponsive. 4. Review and verification of employee signatures of the [DATE]-[DATE] staff in-services on abuse and neglect, vulnerable adult act, resident rights and CPR policy. 5. Review of the mock code drill participation forms to assess and assure that facility staff was following the Facility's CPR policy/protocol. 6. Review of the [DATE] Emergency Quality Assurance meeting. The meeting included the "Problem, Assigned To, Action Taken and Goal Date" regarding " CPR was stopped on a resident with a full code status without notifying EMS". 7. Random staff interviews with Certified Nurses Aides, Licensed Practical Nurses, Registered Nurses, Support staff such as Laundry employees, Housekeeping employees, Maintenance employees and Dietary employees regarding recent in-services on where to find Resident code status, Abuse and Neglect, Vulnerable Adult Act, Resident Rights, CPR Awareness policy and the CPR Policy/Protocol. Based on verification of the facility's corrective actions that were verified by staff interviews and in-service, the SQC and Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] from a "J" to a "D " level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on record review, staff interview and facility policy/procedure review, the facility failed to assure that the services being provided met professional standards of quality for one (1) of eight (8) residents reviewed (Resident #1) as evidenced on [DATE]. It was determined that Substandard Quality of Care (SQC) and Immediate Jeopardy (IJ) were identified on [DATE] at 4:55 p.m. to begin on [DATE]. Resident #1 was found unresponsive, Cardiopulmonary Resuscitation (CPR) was initiated by Registered Nurse (RN) Supervisor and continued for approximately five (5) minutes. The Registered Nurse Supervisor failed to activate Emergency Medical Services (EMS) and Resident #1 expired. Resident #1 was admitted to the facility on [DATE] and her Responsible Party (RP) had completed the Advance Directives electing that Resident #1 be a Full Code. It was determined that an Immediate Jeopardy existed in Professional Standards due to RN #1 not activating EMS after finding Resident #1 unresponsive and confirming she was a Full Code. The Immediate Jeopardy was identified and reported to the facility Administrator and Director of Nurses on [DATE] at 4:55 p.m. The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 4:30 p.m. Verification of the facility's corrective actions was conducted on [DATE] beginning at 4:30 p.m. Based on verification of the facility's corrective actions that were verified by surveyor through staff interviews and documented in-services, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered from a "J " on [DATE] to a "D" level, which constituted no actual harm with potential for more than minimal harm. The facility will remain out of substantial compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings include: Resident #1 Cross Refer to F-309 related to the facility failed to assure that the services being provided met professional standards of quality for one (1) of eight (8) residents reviewed (Resident #1) as evidenced on [DATE] Resident #1 was found unresponsive, Cardiopulmonary Resuscitation (CPR) was initiated by Registered Nurse (RN) supervisor and continued for approximately five (5) minutes. The Registered Nurse supervisor failed to activate Emergency Medical Services (EMS) and Resident #1 expired. Resident #1 was admitted to the facility on [DATE] and her Responsible Party (RP) had completed the Advance Directives electing that Resident #1 be a Full Code. Review of the American Heart Association's website revised 2013 states that the " CHAIN OF SURVIVAL " ' s first step is "Immediate recognition of [MEDICAL CONDITION] and activation of the Emergency Response System". The second step is "Early Cardiopulmonary Resuscitation (CPR) with an emphasis on chest compressions". Review of the "MS Vulnerable Adult Act" revised ,[DATE] states the definition of neglect as "NEGLECT is clarified by inclusion of the reasonably prudent person standard, which is now used to determine what action is necessary by the caretaker, to maintain the vulnerable adult's mental and physical health. Again, only a single incident is necessary for a determination of neglect." ALLEGATION OF COMPLIANCE "On [DATE], at approximately 10:00 p.m., Certified Nursing Assistant (CNA) #1 and CNA #2 entered Resident #1's room and observed the resident to appear unresponsive. RN #1 put oxygen saturation meter on Resident #1's finger with no reading detected at approximately 10:00 p.m. RN #1 went to the nurses ' station and checked Resident #1's medical record to determine her code status at approximately 10:00 p.m. Finding that Resident #1 was a 'Full Code', RN #1 returned to Resident #1's room and initiated cardio [MEDICAL CONDITION] resuscitation (CPR). RN #1 performed CPR on Resident #1 with no results. LPN #1 took over CPR while RN #1 left the room and attempted to call the Director of Nursing (DON) between 10:00 p.m. and 10:30 p.m. RN #1 failed to follow the CPR Awareness Policy and activate Emergency Medical Services (EMS). After an undetermined amount of time, RN #1 re-entered Resident #1's room and instructed LPN #1 to stop CPR at approximately 10:30 p.m. RN #1 returned to the nurse's station and called the (county) County Coroner at approximately 10:35 p.m. and Resident #1's family at approximately 10:45 p.m., to notify them of Resident #1's passing. On [DATE] the (county) County Coroner arrived at approximately 10:45 p.m. and completed a Death Certificate listing the cause of death as 1. [MEDICAL CONDITION] 2. [MEDICAL CONDITION]. On [DATE] at approximately 10:57 p.m., RN #1 notified the DON of Resident #1's passing. The DON questioned RN #1 about Resident #1's code status and identified the fact that R #1 failed to call Emergency Medical Service (EMS) during the code process. On [DATE], at approximately 10:57 p.m., the DON immediately conducted re-education to the Nursing staff regarding what to do when a resident is found unresponsive and has a full code status. On [DATE], at approximately 10:00 p.m., the DON instructed RN #1 to complete her documentation of Resident #1's passing. On [DATE], at approximately 11:09 p.m., the DON contacted the Nursing Home Administrator (ADM) to notify him of RN #1's failure to call EMS during the code process. On [DATE] at approximately 11:09 p.m. the Director of Nursing notified the Administrator of Resident #1's passing and code status. In addition, the Director of Nurses identified the failure of RN #1 to notify Emergency Medical Services on [DATE], at approximately 10:57 p.m. An immediate investigation and corrective steps were implemented including immediate in-service of RN #1 and LPN #1 on the requirement to call EMS during a code by the Director of Nursing at approximately 11:00 p.m. on [DATE]. RN #1 documented the occurrences, and waited for Resident #1's family to arrive between 11:00 p.m. and 12:00 a.m. RN #1 accompanied the family to Resident #1's room. RN #1 waited for the funeral home to pick up Resident #1 at approximately 1:20 p.m., and clocked out at approximately 1:30 a.m. On [DATE], at approximately 7:00 a.m., the Staff Development Nurse (SDC) and Director of Nursing began re-in servicing of the facility staff including Licensed Nurses, CNAs, Therapy Staff, Housekeeping and Laundry Staff, Dietary Staff, Maintenance Staff and Department Heads related to what to do in the event a resident is observed unresponsive. Licensed Nursing Staff were re-in serviced regarding how to determine a code status, what to do if an RN Supervisor does not initiate CPR on a full code status resident, or stops CPR once CPR has been initiated. EMS must be notified and CPR can only be stopped by the order of a physician, or when EMS arrives in the facility and takes charge of the code. Staff was also re-in serviced on abuse and neglect, vulnerable adult, resident rights, and the CPR policy. At approximately 7:00 a.m., Re-in servicing was provided prior to nursing employees being allowed to work their assigned shift. In-services were completed on [DATE]. No staff member was allowed to work prior to re-education. On [DATE], at approximately 10:40 a.m., the Administrator Notified the Medical Director with an adhoc Quality Assurance meeting with the DON, SDC, and Clinical Services Coordinator conducted to review Resident #1's status including her being a full code and emergency medical services not being notified. Also included in the QA discussion were the corrective steps of: ? auditing active resident's code status alert sheet and code status consent form to ensure congruency; ? auditing of active resident's care plans to ensure accurate code status; ? reviewing active resident's code status with the resident, responsible party, and physicians; ? performing mock code drills each shift to include active nursing staff; and ? Auditing of licensed employees CPR. The DON/designee will conduct mock drills weekly for four weeks and monthly thereafter two months to maintain compliance. The DON will report findings to the Quality Assurance Committee for further recommendations. The DON is responsible for overall monitoring and ongoing compliance. " On [DATE], at approximately 11:00 a.m., a comprehensive audit of the eighty four (84) active resident's code status alert sheets, code status consent forms and care plans was completed by the MDS coordinators and Director of Nursing with no negative findings identified. On [DATE] at approximately 7:30 a.m. the staff development coordinator initiated an audit of licensed nursing staff's CPR certification to ensure direct care staff certifications were current; no negative findings were identified. On [DATE] at approximately 12:30 p.m., the Administrator interviewed RN #1 and suspended her pending the outcome of the investigation for not following the CPR Awareness Policy and activating EMS. On [DATE], LPN #1 was not scheduled to work and was informed by the Staff Development Coordinator that she could not return to work until she was interviewed by the Administrator. On [DATE], at approximately 12:15 p.m., LPN #1 was re-interviewed by the Administrator and suspended pending investigation to determine if she followed the CPR Awareness Policy. No additional disciplinary actions were taken against other employees. On [DATE], at approximately 2:50 p.m., the Director of Nurses initiated code drills which were conducted with ,[DATE] and ,[DATE] shifts. Staff responded appropriately. On [DATE], at approximately 11:08 p.m., the Director of Nurses conducted a mock code drill with the ,[DATE] staff, with staff responding appropriately. [DATE], at approx 3:48 p.m., the Mississippi State Department of Health, Licensure & Certification was notified by the Director of Nursing that on [DATE], at approximately 10:00 p.m., CPR was initiated on Resident #1 and RN Supervisor #1 stopped CPR without a physician's orders [REDACTED].#1's failure to follow facility policy related to full code status for Resident #1. On [DATE], at approximately 5:14 p.m., the Mississippi Attorney General's office was notified by the Administrator completing the on-line reporting form of the AG website. Verification of the facility's corrective actions was conducted on [DATE] beginning at 4:30 p.m. were: 1. Review of the [DATE] comprehensive audit of active resident code status alert sheets, code status consent forms and care plans to ensure that all Active Resident charts had the correct "Code Status Alert" sheet, resident "Code Status Consent" forms were signed by the resident or Responsible Party and that "Do Not Resuscitate" (DNR) care plans are on DNR resident charts. 2. Review of the [DATE] audit of licensed nursing staffs CPR certification to assure that all Licensed Practical Nurses and Registered Nurses were CPR certified and Certifications were not out of date. 3. Review and verification of employee signatures of the [DATE]-[DATE] in-services of facility staff concerning what to do if a resident is observed unresponsive. 4. Review and verification of employee signatures of the [DATE]-[DATE] staff in-services on abuse and neglect, vulnerable adult act, resident rights and CPR policy. 5. Review of the mock code drill participation forms to assess and assure that facility staff was following the Facility's CPR policy/protocol. 6. Review of the [DATE] Emergency Quality Assurance meeting. The meeting included the "Problem, Assigned To, Action Taken and Goal Date" regarding " CPR was stopped on a resident with a full code status without notifying EMS". 7. Random staff interviews with Certified Nurses Aides, Licensed Practical Nurses, Registered Nurses, Support staff such as Laundry employees, Housekeeping employees, Maintenance employees and Dietary employees regarding recent in-services on where to find resident code status, Abuse and Neglect, Vulnerable Adult Act, Resident Rights, CPR Awareness policy and the CPR Policy/Protocol. Based on verification of the facility's corrective actions that were verified by staff interviews and in-service, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] from a "J" to a "D " level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on record review, staff interview and facility policy/procedure review, the facility failed to provide the services necessary to avoid harm, mental anguish or mental illness for one (1) of eight (8) residents reviewed, (Resident #1), as evidenced on [DATE]. . Resident #1 was admitted to the facility and her Responsible Party (RP) completed the Advance Directives electing that Resident #1 be a Full Code. On [DATE], Resident #1 was found unresponsive and the Registered Nurse (RN) Supervisor began Cardiopulmonary Resuscitation (CPR) and continued CPR for approximately five (5) minutes. The Registered Nurse Supervisor failed to activate Emergency Medical Services (EMS) and Resident #1 expired. It was determined that an Immediate Jeopardy existed in Neglect due to RN #1's failure of not activating EMS after finding Resident #1 unresponsive and confirming she was a Full Code. It was determined that Substandard Quality of Care (SQC) and Immediate Jeopardy were identified and reported to the facility Administrator and Director of Nurses on [DATE] at 4:55 p.m. The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 4:30 p.m. Based on verification of the facility's corrective actions that were verified by surveyor through staff interviews and documented in-services, the Immediate Jeopardy (IJ) and SQC were removed and the scope and severity was lowered on [DATE] from a " J " to a " D " level, which constituted no actual harm with potential for more than minimal harm. The facility will remain out of substantial compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings include: Resident #1 Cross Refer to F-309 related to the facility's failure to provide the services necessary to avoid harm, mental anguish or mental illness for one (1) of eight (8) residents reviewed, (Resident #1), as evidenced on [DATE]. Resident #1 was found unresponsive, Cardiopulmonary Resuscitation (CPR) was initiated by Registered Nurse (RN) supervisor and continued for approximately five (5) minutes. The Registered Nurse supervisor failed to activate Emergency Medical Services (EMS) and Resident #1 expired. Resident #1 was admitted to the facility and her Responsible Party (RP) completed the Advance Directives electing that Resident #1 be a Full Code. On [DATE] Resident #1 was found unresponsive and the Registered Nurse (RN) Supervisor began Cardiopulmonary Resuscitation (CPR) and continued CPR for approximately five (5) minutes. The Registered Nurse Supervisor failed to activate Emergency Medical Services (EMS) and Resident #1 expired. Review of the American Heart Association's website (revised 2013) stated that the " CHAIN OF SURVIVAL" first step is " Immediate recognition of [MEDICAL CONDITION] and activation of the Emergency Response System " . The second step is "Early Cardiopulmonary Resuscitation (CPR) with an emphasis on chest compressions". Review of the "MS Vulnerable Adult Act" (revised ,[DATE]) states the definition of neglect as "NEGLECT is clarified by inclusion of the reasonably prudent person standard, which is now used to determine what action is necessary by the caretaker, to maintain the vulnerable adult's mental and physical health. Again, only a single incident is necessary for a determination of neglect ". The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 4:30 p.m. ALLEGATION OF COMPLIANCE "On [DATE] at approximately 10:00 p.m. Certified Nursing Assistant (CNA) #1 and CNA #2 entered Resident #1's room and observed the resident appeared unresponsive. RN #1 put oxygen saturation meter on Resident #1's finger with no reading detected at approximately 10:00 p.m. RN #1 went to the Nurses station and checked Resident #1's medical record to determine her code status at approximately 10:00 p.m. Finding that Resident #1 was a 'Full Code', RN #1 returned to Resident #1's room and initiated cardio [MEDICAL CONDITION] resuscitation (CPR). RN #1 performed CPR on Resident #1 with no results. LPN #1 took over CPR while RN #1 left the room and attempted to call the Director of Nursing (DON) between 10:00 p.m. and 10:30 p.m. RN #1 failed to follow the CPR Awareness Policy and activate Emergency Medical Services (EMS). After an undetermined amount of time, RN #1 re-entered Resident #1's room and instructed LPN #1 to stop CPR at approximately 10:30 p.m. RN #1 returned to the Nurse's Station and called the (local) County Coroner at approximately 10:35 p.m. and Resident #1's family at approximately 10:45 p.m. to notify them of Resident #1's passing. On [DATE], the (county) County Coroner arrived at approximately 10:45 p.m. and completed a Death Certificate listing the cause of death as 1. [MEDICAL CONDITION] 2. [MEDICAL CONDITION]. On [DATE] at approximately 10:57 p.m., RN #1 notified the DON of Resident #1's passing. The DON questioned RN #1 about Resident #1's code status and identified the fact that R #1 failed to call Emergency Medical Service (EMS) during the code process. On [DATE] at approximately 10:57 p.m. the DON immediately conducted re-education to the Nursing staff regarding what to do when a resident is found unresponsive and has a full code status. On [DATE] at approximately 10:00 p.m. the DON instructed RN #1 to complete her documentation of Resident #1's passing. On [DATE] at approximately 11:09 p.m., the DON contacted the Nursing Home Administrator (ADM) to notify him of RN #1's failure to call EMS during the code process. On [DATE] at approximately 11:09 p.m. the Director of Nursing notified the Administrator of Resident #1's passing and code status. In addition, the Director of Nurses identified the failure of RN #1 to notify Emergency Medical Services on [DATE] at approximately 10:57 p.m. An immediate investigation and corrective steps were implemented including immediate in-service of RN #1 and LPN #1 on the requirement to call EMS during a code by the Director of Nursing at approximately 11:00 p.m. on [DATE]. RN #1 documented the occurrences, and waited for Resident #1's family to arrive between 11:00 p.m. and 12:00 a.m. RN #1 accompanied the family to Resident #1's room. RN #1 waited for the funeral home to pick up Resident #1 at approximately 1:20 p.m., and clocked out at approximately 1:30 a.m. On [DATE], at approximately 7:00 a.m., the Staff Development Nurse (SDC) and Director of Nursing began re-in servicing of the facility staff including Licensed Nurses, CNAs, Therapy Staff, Housekeeping and Laundry Staff, Dietary Staff, Maintenance Staff and Department Heads related to what to do in the event a resident is observed unresponsive. Licensed Nursing Staff were re-in serviced regarding how to determine a code status, what to do if an RN Supervisor does not initiate CPR on a full code status resident, or stops CPR once CPR has been initiated. EMS must be notified and CPR can only be stopped by the order of a physician, or when EMS arrives in the facility and takes charge of the code. Staff was also re-in serviced on abuse and neglect, vulnerable adult, resident rights, and the CPR policy. At approximately 7:00 a.m., Re-in servicing was provided prior to nursing employees being allowed to work their assigned shift. In-services were completed on [DATE]. No staff member was allowed to work prior to re-education. On [DATE], at approximately 10:40 a.m., the Administrator Notified the Medical Director with an adhoc Quality Assurance meeting with the DON, SDC, and Clinical Services Coordinator conducted to review Resident #1's status including her being a full code and emergency medical services not being notified. Also included in the QA discussion were the corrective steps of: ? auditing active resident's code status alert sheet and code status consent form to ensure congruency; ? auditing of active resident's care plans to ensure accurate code status; ? reviewing active resident's code status with the resident, responsible party, and physicians; ? performing mock code drills each shift to include active nursing staff; and ? auditing of licensed employees CPR. The DON/designee will conduct mock drills weekly for four weeks and monthly thereafter two months to maintain compliance. The DON will report findings to the Quality Assurance Committee for further recommendations. The DON is responsible for overall monitoring and ongoing compliance. " On [DATE], at approximately 11:00 a.m., a comprehensive audit of the eighty four (84) active resident's code status alert sheets, code status consent forms and care plans was completed by the MDS coordinators and Director of Nursing with no negative findings identified. On [DATE] at approximately 7:30 a.m. the staff development coordinator initiated an audit of licensed nursing staff's CPR certification to ensure direct care staff certifications were current; no negative findings were identified. On [DATE] at approximately 12:30 p.m., the Administrator interviewed RN #1 and suspended her pending the outcome of the investigation for not following the CPR Awareness Policy and activating EMS. On [DATE], LPN #1 was not scheduled to work and was informed by the Staff Development Coordinator that she could not return to work until she was interviewed by the Administrator. On [DATE], at approximately 12:15 p.m., LPN #1 was re-interviewed by the Administrator and suspended pending investigation to determine if she followed the CPR Awareness Policy. No additional disciplinary actions were taken against other employees. On [DATE], at approximately 2:50 p.m., the Director of Nurses initiated code drills which were conducted with ,[DATE] and ,[DATE] shifts. Staff responded appropriately. On [DATE], at approximately 11:08 p.m., the Director of Nurses conducted a mock code drill with the ,[DATE] staff, with staff responding appropriately. [DATE], at approx 3:48 p.m., the Mississippi State Department of Health, Licensure & Certification was notified by the Director of Nursing that on [DATE], at approximately 10:00 p.m., CPR was initiated on Resident #1 and RN Supervisor #1 stopped CPR without a physician's orders [REDACTED].#1's failure to follow facility policy related to full code status for Resident #1. On [DATE], at approximately 5:14 p.m., the Mississippi Attorney General's office was notified by the Administrator completing the on-line reporting form of the AG website. " Verification of the facility's corrective actions was conducted on [DATE] beginning at 4:30 p.m. included: 1. Review of the [DATE] comprehensive audit of active resident code status alert sheets, code status consent forms and care plans to ensure that all Active Resident charts had the correct " Code Status Alert " sheet, resident " Code Status Consent " forms were signed by the Resident or Responsible Party and that " Do Not Resuscitate " (DNR) care plans are on DNR Resident charts. 2. Review of the [DATE] audit of licensed nursing staffs CPR certification to assure that all Licensed Practical Nurses and Registered Nurses were CPR certified and Certifications were not out of date. 3. Review and verification of employee signatures of the [DATE]-[DATE] in-services of facility staff concerning what to do if a resident is observed unresponsive. 4. Review and verification of employee signatures of the [DATE]-[DATE] staff in-services on abuse and neglect, vulnerable adult act, resident rights and CPR policy. 5. Review of the mock code drill participation forms to assess and assure that facility staff was following the Facility's CPR policy/protocol. 6. Review of the [DATE] Emergency Quality Assurance meeting. The meeting included the " Problem, Assigned To, Action Taken and Goal Date " regarding " CPR was stopped on a resident with a full code status without notifying EMS " . 7. Random staff interviews with Certified Nurses Aides, Licensed Practical Nurses, Registered Nurses, Support staff such as Laundry employees, Housekeeping employees, Maintenance employees and Dietary employees regarding recent in-services on where to find Resident code status, Abuse and Neglect, Vulnerable Adult Act, Resident Rights, CPR Awareness policy and the CPR Policy/Protocol. Based on verification of the facility's corrective actions that were verified by staff interviews and in-service, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] from a "J" to a "D " level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on observation, record review, staff interview, and policy review the facility failed to ensure that residents remained free of accident hazards as possible. This was for one (1) of five (5) residents reviewed, Resident #4. On 2/23/12, Resident #4 was served hot coffee and spilled it on his abdomen resulting in a 30 centimeter (cm) (11.81 inches) in length and 5 (five) cm (1.96 inches) in width burn. The burn to the abdomen was red with an open blister that measured 1 (one) cm (0.393 inches) by one (1) cm open blister at the naval area. The temperature of the coffee, in the coffee dispenser was tested approximately one (1) hour after Resident #4 incurred the burn and was recorded as 140 degrees Fahrenheit (F). The facility policy stated that the coffee temperature should be 135 degrees (F) prior to serving to the Residents. Findings Include: Record review revealed that Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/7/12 revealed that Resident #4 was moderately cognitively impaired with decisions poor, cues/supervision required. Eating skill was coded as independent with set up help only. Observation on 3/26/12 at 10:20 a.m. revealed that Resident #4 was sitting in a wheelchair with a lap tray and an body alarm in connected to the resident's clothing and the wheelchair. The wheelchair was near the Nurse's Station. Resident #4 was able to state his name. At 12:05 p.m. Resident #4 was observed in the dining room eating the lunch meal. There were two (2) glasses containing liquids on the meal tray and neither of the glasses had a lid to prevent the spillage of the liquid. Review of Resident #4 's meal tray ticket dated 3/26/12 for the Lunch meal revealed, "Sippy Cup, No Straws " . Review of Resident #4 's January 2012 computerized "Physician Orders" revealed an order on "5/10/11 stating: " Resident to have sippy cup with all meals". Observation on 3/26/12 at 12:20 p.m. revealed that Resident #4 had a small reddened area near the naval area. The Treatment Nurse was present and stated that area was where the blister had healed that was caused by the coffee burn. Review of a facility document "Alleged Abuse/Neglect Initial Report" revealed a date of occurrence of 2/23/12 at approximately 2:10 p.m. and that "yes" the resident was injured. "The description of the injury was a 30 centimeter (cm) (11.81 inches) in length and 5 (five) cm (1.96 inches) in width. The injury was to the abdomen and was red with an open blister that measured 1 (one) cm (0.393 inches) by 1 cm open blister at the naval area. Resident #4 had requested a cup of coffee and the Activities Assistant provided the coffee to Resident #4. A few minutes later the Activities Assistant heard Resident #4 state that the coffee had spilled". The facility "Alleged Abuse/Neglect Investigation Report" revealed "Resident was sitting in wc (wheelchair) in the entrance way of the dining room. Resident requested a cup of coffee. Activities assistant gave him a cup of coffee and stated a few min (minutes) later stated he had spilled the coffee also @ (at) this time another CNA (Certified Nursing Assistant #1) witnessed him spill the coffee and got him and brought him down the hall for the CNA (CNA #2) to change him and that is when the redness was noted. Resident #4 stated he had spilled his coffee". Review of the facility "Incident Report" dated 2/23/12 revealed that Resident #4 complained of pain and Silvadene Cream was applied to "cool burn off". Section E of that report revealed that Resident #4 did not know the coffee was going to spill and that Resident #4 did not have hand tremors. "What was done during or immediately after this incident to protect the resident from further injury or risk of injury, and to prevent future recurrences of this incident? Assessment of his body. Sippie cup for all hot liquids. OT (Occupational Therapy) screen". Review of the "Interdisciplinary Therapy Screening Form" dated 2/24/12 revealed that "OT recommends (for Resident #4) hot beverages be served in sippie cup to prevent burns from spills." Interview was conducted on 3/26/12 at 1:33 p.m. with the Activity Assistant and revealed that on 2/23/12 at "about 1:45 (p.m.)", while preparing for Bingo, Resident #4 was sitting in the entrance way to the Dining Room in a wheelchair with a lap tray and was requesting coffee. The Activity Assistant got the coffee from a thermos by the kitchen door and gave to Resident #4. The Activity Assistant heard Resident #4 state "Ow" and noticed a wet spot by the lap tray. Resident #4 replied "That's hot coffee." The Activity Assistant concurred with Resident #4 and stated "I know it's hot". Changing of the shirt was offered and Resident #4 declined. Interview with the Dietary Manager on 3/26/12 at 2:34 p.m. revealed: "Now, have to get (coffee) to 135 degrees before we set out- was supposed to be 135 (degrees) (F) then". The temperature of the coffee that was in a thermos in the Dining Room at that time revealed the temperature to be 120 degrees (F) and the Dietary Manager stated that when the coffee was brought to the Dining Room the temperature was 135 degrees (F) and that the thermos had been in the Dining Room since 6:45 a.m. Interview with Dietary Aide #1 on 3/27/12 at 7:55 a.m. revealed that when the coffee was removed from the brewer the temperature would be 180 degrees and the coffee would have to sit for about one (1) hour before the temperature would reach 135 degrees (F). The Dietary Aide #1 stated that the practice had been in place for about three (3) months after "somebody got burned". On 3/26/12 at 8:57 a.m. revealed that the temperature of the coffee in the thermos in the Dining Room was 135 degrees (F). Resident #5 ambulated into the Dining Room and approached the Surveyor and the Dietary Manager and stated that the coffee was not hot enough when it was served to the Residents. Interview with Dietary Aide #2 on 3/27/12 at 9:12 a.m. revealed that the coffee was poured into the thermos about 6:00 a.m. and the temperature was to supposed to be 135 degrees (F). "I get busy and it may sit over one (1) hour. They (residents) have fussed every morning about the temperature of the coffee being too cool now. Interview with CNA #2 on 3/27/12 at 10:20 a.m. revealed that on the day Resident #4 spilled his coffee it was between 1:30 and 2:00 p.m. while she was conducting her last rounds. CNA #2 stated: "A restorative CNA was bringing him down the hall (and) said (Resident #4) needs changing. Took (him) to room. Changing clothes he usually hollers a good bit. Putting diaper on and he said "Oh that hurts". (Skin) was faint red-pink. Nurse was on the hall and we got her in there. She looked at it and said to go ahead and dress him. Put him in wheelchair, lap tray- he said it was really hurting him. Around 2:45 (p.m.) was charting- he motioned for me - his lap board (tray) was on- said get this off. I lifted shirt and saw blister. Showed nurse." Interview with CNA #1 on 3/27/12 at 10:38 a.m. confirmed that on 2/23/12 Resident #4 was in the doorway of the Dining Room when the Activity Assistant provided coffee to Resident #4 and it spilled on the Resident. The Activity Assistant took the coffee from Resident #4 and cleaned the lap tray off and gave the coffee back to Resident #4. CNA #1 went on about the task of putting ice in an ice chest and came back by the Dining Room within a minute and Resident #4 had spilled the rest of the coffee and was swearing-"said it's hot". CNA #1, then took Resident #4 to the Nursing Unit and reported the incident to Resident #4's CNA, Nurse and the Director of Nursing. Review of a statement dated 2/23/12 with two (2) Dietary Staff members signatures revealed; "Put coffee in Dining Room, was instructed by Dietary Manager to check temp (Temperature). Temp was at 140 degrees (F)". Review of the facility policy "Hot Beverages-Temperature Notification" dated 9-8-08 revealed, "Burn depth is directly related to the temperature of the burning agent and the duration of contact with body tissue. Below 112 degrees Fahrenheit (F), no local damage occurs unless exposure is for an protracted period. At 120 degrees F, it takes 5 minutes exposure to create a full-thickness burn. At 125 degrees F, it takes 2 minutes exposure to create a full-thickness burn and only 6 seconds at 140 degrees F. Based on evidentiary and educational review, the policy for the temperature of hot beverages served at the facility has been modified. The policy related to temperature is that hot beverages will not be served out or reheated to exceed a serving temperature of 135 degrees Fahrenheit. Therefore, hot beverages are not to be made available to residents unless there is a confirmed temperature of 135 degrees or less." Review of a statement with the Dietary Managers name revealed, "On February 23, 2012 had an issue with temperature on coffee called facility and talked with (Name of Cook #1) PM cook. I instructed cook to take a temperature of the coffee that was placed in the dining room but before taking temperature to make sure to calibrate thermometer. (Name of Cook Aide #1) took temperature and it was at 140 degrees (F). With the issue at hand I will do an in-service and post a hot beverage temperature log to be taken before putting any coffee in the dining room from dietary. The temperature should be at 135 degrees (F) per (name of facility) Policy unless special permission is given." Review of a facility document titled "Coffee/Hot Liquids Serving Procedures" revealed: "The following procedures related to coffee/Hot Liquid Drinks service for our Residents must be followed. Dietary is not allowed to give "single servings" of coffee through the kitchen door. *1) Dietary Employees will transfer coffee from the coffee maker to a holding container in the kitchen. *2) Dietary Employees will check the temperature of the coffee as it cools to 135 Degrees Fahrenheit. *3. Dietary Employee will transfer coffee at 135 Degrees to the serving containers and send out for Resident consumption. *4. Dietary Employees are responsible for keeping a Hot Liquids Temperature Log to document the temperature of coffee and any other hot liquid drink served from the Dietary Department." Review of a facility document "Hot Beverage Temperature Record" dated February 2012 revealed no documented temperatures until 10:55 a.m. on 2/23/12 with a recorded temperature of 135 degrees (F). The next temperature was documented at 3:15 p.m. and was recorded at 140 degrees (F). Resident #4 spilled coffee that was served at approximately 2:10 p.m. (according to facility document). Interview with the Dietary Manager on 3/27/12 at 10::00 a.m. confirmed that the temperature of the coffee that was placed in the Dining Room and served to the Residents on 2/23/12 was not checked prior to being made available to Residents. The Dietary Manager confirmed that on 2/23/12 a conversation was conducted with Cook Aide #1 and confirmed that the coffee put in the Dining Room on 2/23/12 for the afternoon Activity did not have the temperature checked prior to Resident #4 spilling coffee and obtaining a 30 cm x 5 cm burn with a blister measuring 1 cm x 1 cm at the naval area.