Every finding on record at James T Champion

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's call light was maintained within reach as a reasonable accommodation for one (1) of (16) sampled residents. Resident #27.Findings include:A review of the facility's policy, Call Bell/Light, dated July 2024, revealed, .residents will have access to a call bell/light apparatus.3. Procedure A. Nursing Services will ensure that the call bell/light is within easy reach of the resident.A record review of the facility's Professional Development Program Record, dated 1/6/26 and 1/8/26, revealed, .Course Goals & Learning Objectives.Call bell should be within reach at all times.On 2/2/26 at 12:44 PM, during an observation, Resident #27 was observed lying in bed asleep. The resident's call light was observed on the floor beside the bed rather than within reach. Although the call light had a clip attached, it was not secured to the resident, the bed linens, or the bed, leaving it inaccessible to the resident while in bed.On 2/2/26 at 12:50 PM, during an observation and interview with Certified Nursing Aide (CNA) #1, Resident #27's call light was on the floor beside the bed and out of the resident's reach. CNA #1 confirmed staff were trained so that call lights were to be left within resident reach.On 2/4/26 at 10:32 AM, during an interview, CNA #3, who is the CNA Coordinator, reported all CNA staff were trained to ensure call lights were within reach when leaving a resident's room, regardless of whether the resident could independently use the call light. She reported that staff received monthly in-service education and daily reminders regarding call light placement.On 2/5/26 at 9:45 AM, during an interview, the Director of Nursing (DON) reported her expectation was for staff to ensure residents were left with the call light within reach when exiting the resident's room.A record review of the Face Sheet revealed the facility admitted Resident #27 on 12/21/23 with diagnoses including Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/25 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of one (1), which indicated his cognition was severely impaired.

Based on interview and record review, the facility failed to ensure as-needed (PRN) orders for psychotropic medications were limited to (14) days unless the medication was re-evaluated and a duration was specified for one (1) of five (5) residents reviewed for unnecessary medications. Resident #13.Findings include:A record review of the Resident Face Sheet revealed the facility admitted Resident #13 on 7/18/25 with diagnoses including Senile Degeneration of Brain and Persistent Mood Disorder.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/26 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident's cognition was severely impaired. Section N revealed the resident was receiving antipsychotic, antianxiety, and antidepressant medications.A record review of Resident #13's Physician Order Report dated 2/1/26 through 2/28/26 revealed an order with a start date of 8/1/25 for Lorazepam (Ativan) two (2) mg per milliliter (ml), give 0.5 ml sublingual every three (3) hours PRN for air hunger or anxiety. The order did not include a specified duration or evidence of re-evaluation every (14) days.On 2/3/26 at 2:07 PM, during an interview, Licensed Practical Nurse (LPN) #3 reported Resident #13 was receiving Ativan and Morphine. She reported the resident was monitored for decreased agitation and pain with Morphine and decreased agitation with Ativan and stated the resident was compliant with care and medications.On 2/5/26 at 11:15 AM, during a follow-up interview and record review with the Director of Nursing, she reported Resident #13 was on Lorazepam per hospice recommendations. She reported she believed the (14) day PRN requirement did not apply to hospice residents.On 2/5/26 at 11:30 AM, during an interview, the Nurse Practitioner reported she continued Lorazepam per hospice recommendations for comfort measures and stated she was not aware the (14) day PRN requirements applied to hospice residents but would apply this requirement going forward.

Based on observation, interview, and record review the facility failed to ensure a tube feeding bag was labeled with required information, including the date, time, type of feeding, and initials of the nurse preparing the tube feeding, in accordance with professional standards, for one (1) of two (2) residents reviewed for tube feeding. Resident #11.Findings include:A record review of the Resident Face Sheet revealed the facility admitted Resident #11 on 12/31/25 with diagnoses including Alzheimer's Disease.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/6/26 revealed Resident #11 required a staff assessment for cognitive status and indicated her cognitive skills for daily decision making was severely impaired.A record review of the Physician Order Report: 02/01/2026 - 02/28/2026 revealed Resident #11 had a Physician's Order, dated 1/14/26 for Isosource 1.5 at 20 ML/HR (Milliliters per Hour) .On 2/2/26 at 12:32 PM, during an observation of Resident #11 and the resident's room, there was a tube feeding bag in use did not contain a date, time, type of feeding or initials of the nurse who prepared or hung the tube feeding.On 2/2/26 at 12:35 PM, during an observation and interview with the Director of Nursing (DON), she reviewed Resident #11's tube feeding bag and confirmed it did not contain a date, time, type of feeding, or initials of the nurse who hung the bag. She reported the night nurse who changes the tube feeding bag is responsible for labeling the bag. She explained the purpose of the labeling is to ensure the feeding bag is changed within (24) hours from the start of use.

Based on observation, interview and record review the facility failed to post required cautionary signage to indicate oxygen was in use for three (3) of (3) residents reviewed for oxygen administration. Residents #1, #11, and #39.Findings include:On 02/02/2026 at 2:17 PM, an observation of the residents' rooms and doors on 200-hall revealed 3 rooms (Residents #1, #11 and #39) where oxygen concentrators were in use with no sign cautioning that oxygen was in use posted on the doors. On 02/02/2026 at 3:09 PM, an interview and observation with the Director of Nursing (DON) confirmed there were no oxygen signs posted outside Residents #1, #11 and #39's doors. The DON noted the reason for having an oxygen sign posted is to inform people that a possible combustible is in this room. The DON affirmed that all nursing staff are responsible for assuring proper signage is posted on residents' doors. The DON noted she will put the signs up and will make sure that the staff are educated to perform this task.On 02/05/2026 at 1:30 PM, during an interview the Administrator acknowledged the failure of the facility's staff to place oxygen signs on Residents #1, #11 and #39's doors. The Administrator stated that the staff will be trained to make sure there are signs posted on all rooms that contain oxygen concentrators.Resident #1A record review of the Resident Face Sheet revealed the facility admitted Resident #1 on 10/18/24 with diagnoses including Tracheostomy.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/22/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating his cognition was intact. A record review of the Physician Order Report: 02/01/2026-02/28/2026 revealed Resident #1 had a Physician's Order, dated 10/31/2024, for O2 (Oxygen) via trach (Tracheostomy) collar - Flow 5L/Min (Liters per minute) .continuous. Resident #11A record review of the Resident Face Sheet revealed the facility admitted Resident #11 on 12/31/2025 with diagnoses including Alzheimer's disease with late onset. A record review of the admission MDS with an ARD of 01/06/2026 revealed Resident #11 required a staff assessment for mental status and his cognitive skills for daily decision making was severely impaired. A record review of the Physician Order Report: 02/01/2026-02/28/2026 revealed Resident #11 had a Physician's Order, dated 12/31/2025 for O2 at 2L per NC (Nasal Cannula).PRN (as needed). Resident #39 A record review of the Resident Face Sheet revealed the facility admitted Resident #39 on 12/15/2025 with diagnoses including Malignant Neoplasm of Esophagus. A record review of the admission MDS with an ARD of 12/21/2025 revealed Resident #39 had a BIMS score of 15 which indicated his cognition was intact. A record review of the Physician Order Report: 02/01/2026-02/28/2026 revealed Resident #39 had a Physician's Order dated 12/17/2025 for O2 at 2L via NC - continuous.

Based on observation, interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection during medication administration for two (2) of five (5) residents observed. Specifically, for Resident #30, staff failed to maintain clean supplies by returning a box of gloves taken into the resident's room to a clean linen cart, and for Resident #5, staff failed to follow enhanced barrier precaution requirements by not wearing an isolation gown during medication administration via percutaneous endoscopic gastrostomy (PEG) tube.Findings include:A review of the facility's policy, Infection Control Plan 2025 - 2026, dated March 2024, revealed, .The mission of the infection.prevention, and control program is to prevent and control infections and to promote the well-being of patients, healthcare workers, and visitors through a commitment to excellent.patient care, effective use of resources, and continuous improvement.A review of the facility's Enhanced Barrier Precautions Protocol, undated, revealed, 1. Enhanced Barrier Precautions (EBP) are required for the following resident categories: All residents with multidrug-resistant organisms (MDROs)., chronic wounds or indwelling medical devices. A green sticker will be placed on the outside of the resident's door to identify residents on EBP. 3. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities.Device care or use.feeding tube.A record review of the facility's Professional Development Program Record revealed Licensed Practical Nurse (LPN) #3 and LPN #2 received education on hand hygiene, contact precautions, enhanced barrier precautions, and personal protective equipment (PPE) on from 5/20/25 through 5/22/25.A record review of the Review Check-Off List revealed LPN #3 received training related to Infection Prevention on 10/27/25.Resident #5A record review of the Resident Face Sheet revealed the facility admitted Resident #5 on 6/2/23 with diagnoses including Dysphagia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/1/25 revealed Resident #5's Brief Interview for Mental Status (BIMS) was not completed and coded as 99. A record review of the Physician Order Report: 02/01/2026 - 02/28/2026 revealed all medications for Resident #5 were to be administered per PEG or PO (by mouth). On 2/4/26 at 7:30 AM, during an observation and interview, Licensed Practical Nurse (LPN) #2 administered medications via PEG tube to Resident #5. A green enhanced barrier precaution indicator was observed on the resident's door. However, the nurse did not wear an isolation gown during the medication administration. LPN #2 confirmed she did not wear an isolation gown while administering medications via PEG tube and stated she believed gowns were only required for residents on contact isolation.On 2/4/26 at 8:00 AM, during an interview, Registered Nurse (RN) #1 stated staff are trained to wear isolation gowns when providing care to residents identified with enhanced barrier precautions and that green indicators on doors identify required personal protective equipment.On 2/4/26 at 8:30 AM, during an interview, the Director of Nursing (DON) stated staff are expected to wear gowns when providing PEG tube care for residents on enhanced barrier precautions and confirmed the nurse failed to follow facility policy.Resident #30A record review of the Resident Face Sheet revealed the facility admitted Resident #30 on 2/20/25 with diagnoses including Allergic Rhinitis.A record review of the Quarterly MDS with an ARD of 11/10/25 revealed Resident #30 had a BIMS score of 12, which indicated her cognition was moderately impaired.A record review of the Physician Order Report: 02/01/2026 - 02/28/2026 revealed Resident #30 had a Physician's Order, dated 6/26/25 for Saline Nasal Spray.On 2/3/26 at 8:35 AM, during an observation, LPN #3 removed a full box of gloves from a clean linen cart, entered Resident #30's room, administered nasal saline spray, and then returned the box of gloves to the clean linen cart.On 2/3/26 at 9:00 AM, during an interview, LPN #3 stated she placed the gloves back on the clean linen cart after use and did not believe the gloves were contaminated once taken into the resident's room. LPN #3 returned the gloves back to Resident #30's room and stated she didn't care because she didn't pay for them.On 2/5/26 at 8:15 AM, during an interview, the Director of Nursing (DON) stated gloves are considered contaminated once taken into a resident's room and should not be returned to the clean supply areas. The DON stated staff are expected to remove only the gloves needed for resident care and to follow infection control policies.On 2/5/26 at 1:00 PM, during an interview, the Administrator stated staff are expected to always follow infection control and enhanced barrier precaution policies. The Administrator confirmed staff should not return supplies taken into resident rooms to clean areas and should wear gowns when administering PEG tube medications.

Based on observation, interview, record review, and facility policy review, the facility failed to assess the risks associated with the use of bed rails, obtain resident consent, and conduct ongoing evaluations for continued use of bed rails for one (1) of one (1) resident reviewed for bed rail use, Resident #18. This failure had the potential to affect 40 of 63 residents residing in the facility who used side rails. Findings included: A review of the statement provided by the Administrator dated 4/24/25 revealed, There is currently no policy for bed rails . A review of the Siderails and Assist Device Owner's Manual for the bed type used for Resident #18 revealed, . A licensed healthcare provider should investigate the potential risk for entrapment on an individual basis . On 4/21/25 at 12:39 PM, Resident #18 was observed lying in bed with the head of the bed elevated. Half side rails were observed padded on both sides and were raised on the upper half of the bed. Resident #18 denied having any seizures and stated that the side rails had always been present since her admission, but she was not sure why they were in place. A record review of a list of current residents in the facility with side rails revealed 40 residents out of 63 had side rails as of 4/24/25. A record review of Resident #18's Face Sheet revealed the facility admitted the resident on 9/25/23 with diagnoses including Alzheimer's Disease. A record review of Resident #18's Physician Order Report revealed an order dated 9/25/23 for half-length padded side rails to aid with turning and positioning. A record review of Resident #18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired. A further review of Resident #18's medical record revealed no documented quarterly assessments for continued bed rail use and no signed consent for the bed rails. On 4/22/25 at 1:35 PM, during an interview with Certified Nurse Aide (CNA) #1, she explained that most residents have side rails to assist with turning and repositioning. She denied that Resident #18 had any recent falls or seizures and reported that the resident had used side rails as long as she could remember. On 4/22/25 at 3:00 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that Resident #18 had used side rails for as long as she had worked at the facility. She was not sure why the bed rails were padded but confirmed the resident used them to assist with repositioning. On 4/23/25 at 3:40 PM, during an interview with the Administrator, she reported she was not aware of the regulations regarding bed rails. She confirmed the facility did not have signed resident consents for the use of bed rails and that residents had not been assessed for the risk of entrapment. On 4/24/25 at 10:10 AM, during an interview with the Director of Nursing (DON), she confirmed that Resident #18 had no signed consent for side rails and no assessment for the use of bed rails or entrapment risk. She reported that this was true for all residents with bed rails in the facility. She stated that because the rails were used as enablers and not restraints, they had not believed that consent or assessments were required. She confirmed Resident #18 had a physician's order for half-length padded bedrails for turning and positioning dated 9/25/23.

Based on observation, interview, and record review, the facility failed to ensure the safe maintenance and monitoring of bed rails in accordance with manufacturer guidelines for one (1) of one (1) resident observed with side rails, Resident #18, which resulted in the lack of required inspections and documentation for side rail safety with the potential to affect 40 of 63 residents who use side rails. Findings include: A record review of the facility's policy statement dated 4/24/25 revealed, There is currently no policy for bed rails. A review of the Siderails and Assist Device Owner's Manual for the bed type used for Resident #18 revealed, .Maintenance/Inspection Information: Visually inspect the assist handle and mounting bracket, and check for loose hardware on a monthly basis . A licensed healthcare provider should investigate the potential risk for entrapment on an individual basis . A record review of a list of current residents in the facility with side rails revealed that forty (40) out of sixty-three (63) residents had side rails as of 4/24/25. During an observation on 4/21/25 at 12:39 PM, Resident #18 was lying in bed with the head of the bed elevated. Half-length padded side rails were observed on both sides of the upper half of the bed. The resident denied any history of seizures and stated the side rails have just been that way and she did not know why, ever since she had been at the facility. During an interview on 4/23/25 at 10:10 AM, the Director of Nursing (DON) confirmed Resident #18 had half-length side rails on the bed. She reported being unaware of regulations and requirements related to side rail use. During an interview on 4/23/25 at 10:10 AM, the facility's Administrator reported the facility did not have any regular maintenance logs for bed rails. During an interview on 4/23/25 at 11:45 AM, the Maintenance Director confirmed he did not maintain any logs for bed rail inspections. He stated the facility had two (2) types of beds and that he was not aware maintenance logs or regular rounds were required by manufacturer guidelines. A record review of Resident #18's Face Sheet revealed the facility admitted the resident on 9/25/23 with diagnoses including Alzheimer's Disease. A record review of Resident #18's Physician Order Report revealed an order dated 9/25/23 for half-length padded side rails to aid with turning and positioning. A record review of Resident #18's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to privacy of treatment information for one (1) of sixteen (16) sampled residents (Resident #5), when a turning schedule was publicly posted in the resident's room. Findings included: A review of the facility's policy, Rights and Responsibilities of Residents, dated October 2023, revealed, .Resident rights which states 'residents are treated with dignity and respect which includes privacy in treatment and care for their personal needs .3. Procedure .F .will ensure that each resident admitted to the facility is .10. Treated with respect and full recognition of their dignity .including privacy in treatment and care . A record review of the Face Sheet revealed the facility admitted Resident #5 on 9/3/24 with diagnoses including Cerebral Palsy. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/25 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident's cognition was moderately impaired. On 4/21/25 at 12:53 PM, during an observation, Resident #5 was lying in bed, and a turning schedule was visibly posted at the head of the bed on the bulletin board, listing scheduled repositioning times. On 4/23/25 at 1:45 PM, during a follow-up observation, the turning schedule remained posted above the head of the bed in Resident #5's room. The schedule was affixed to the bulletin board located at the head of the bed, making it clearly visible to any person entering the resident's room. On 4/23/25 at 3:09 PM, during an interview and observation with Certified Nurse Aide (CNA) #3, she stated the turning schedule posted in Resident #5's room served as a reminder for staff to turn the resident every two (2) hours. The aide confirmed this practice was used routinely to prompt repositioning in accordance with the resident's care plan. On 4/23/25 at 3:36 PM, during an interview with the Certified Nursing Coordinator (CNC), she confirmed turning schedules were posted in resident rooms as visual reminders for Certified Nurse Aides (CNAs) to reposition residents every two hours or as needed based on care needs. Regarding Resident #5, the CNC stated there was a physician's order for side-to-side turning due to a pressure ulcer. She confirmed the order was documented in the medical chart, and the resident's family had not provided permission for the signage. On 4/23/25 at 4:08 PM, during an interview with the Nurse Supervisor, she stated the facility did not have a formal policy regarding the use of posted turning schedules in resident rooms. The schedules were used as reminders for CNAs to reposition residents every two (2) hours. She confirmed no families had given permission for use of these signs. On 4/24/25 at 2:09 PM, during an interview with the Director of Nursing (DON), she acknowledged her staff had informed her of the signage in Resident #5's room. She stated she had forgotten the signs were still in place and had not taken action to remove them. On 4/24/25 at 2:58 PM, during an interview with the Administrator, she acknowledged she was made aware there was posted signage in Resident #5's room indicating a schedule the staff were to turn the resident. She stated the facility's immediate plan included removal of all such signage, a review of applicable federal regulations, and provision of staff education. She further stated the facility planned to remove all signage containing clinical information regardless of format to ensure full compliance with privacy regulations.

Based on interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be treated with respect and dignity when a Certified Nurse Aide (CNA) would not provide assistance requested by the resident for one (1) of five (5) sampled residents. Resident #1. Findings included: A review of the facility's policy titled Rights and Responsibilities of Residents, revised October 2023, revealed, .It is the policy .to protect and support the fundamental human, civil, and constitutional rights of each resident .Procedure .F .ensure that each resident admitted to the facility is . (10) Treated with respect and full recognition of their dignity and individuality . A record review of the December 2024 Physician's Orders revealed Resident #1 had an order dated 11/7/2024, for one-person assistance with transfers, dressing, and bathing tasks to reduce the resident's risk of falls. A record review of the facility's investigation Vulnerable Adult Act, dated 11/11/2024 and completed on 11/15/2024, revealed that the facility received a complaint on 11/14/2024 regarding an incident involving Resident #1 and CNA #2 that occurred on 11/11/2024 between 8:00 PM and 10:00 PM. The report indicated Resident #1 pressed the call bell to request assistance with changing clothes and getting into bed. CNA #2 entered the room and reportedly refused to assist Resident #1 with the requested tasks, stating, I am only here to assist with toileting. CNA #2 was observed leaving Resident #1's room without providing the requested assistance. The report noted that Resident #1 was care-planned for staff assistance with transfers, toileting, dressing, and bathing to reduce fall risks. Section X of the facility's investigation confirmed the allegation indicating, The allegation is supported by a preponderance of the evidence . On 1/2/2025 at 10:15 AM, during an interview, Resident #1 recounted the incident. She stated she pressed her call bell and explained her needs to three CNAs who responded. CNA #2 informed her that only toileting assistance would be provided and refused to help her change clothes or get into bed. Resident #1 described CNA #2's demeanor as condescending and rude, though no foul language was used. Ultimately, another CNA assisted her with changing clothes and getting into bed. Resident #1 expressed dissatisfaction with CNA #2's behavior, calling it dismissive and unprofessional. On 1/2/2025 at 10:50 AM, during an interview, the CNA Supervisor #1 stated CNA #2 worked night shifts but was no longer employed at the facility. She described CNA #2 as a competent aide but noted prior instances of poor attitude toward co-workers. She emphasized that CNAs are responsible for providing safe and respectful care to residents and should not engage in disagreements with residents. She stated that CNAs must consult a nurse if they have questions about care. On 1/2/2025 at 12:30 PM, during an interview, the Nursing Home Administrator explained that the investigation into the 11/11/2024 incident revealed CNA #2 had refused to assist Resident #1 and may have been rude and disrespectful toward the resident. She stated that statements were collected by both her and the Director of Nursing (DON) and were forwarded to the facility investigator. The Administrator noted that CNA #2, a contract worker, was removed from the schedule pending the investigation but resigned on 11/14/2024 before the investigation concluded. A record review of the Face Sheet revealed the facility admitted Resident #1 on 8/23/2024, with current diagnoses including Heart Disease. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact.

Based on staff interviews, record review, and facility policy review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR) for a resident with a new mental health diagnosis for one (1) of four (4) PASARRs reviewed. Resident #29. Findings include: A review of the facility's policy, Psychiatric Services: Statement of Purpose, revised January 2022, revealed, .Procedure (2) (a) When a resident receives a new mental health diagnosis, a change in status form will be completed by the Psychiatric NP and the Licensed Social Worker and submitted to Mississippi Preadmission Screening and Resident Review (PASRR) requesting a Level II Screening. Record review of the Face Sheet revealed the facility admitted Resident #29 on 8/03/17 with diagnoses that included Major Depressive Disorder and Anxiety Disorder. Record review of Resident #29's Diagnosis/History revealed the diagnosis of Bipolar II Disorder had an Onset date of 5/20/2019, and the diagnosis of Delusional Disorders had an Onset date of 9/16/2020 which were added after her admitted [DATE]. An interview on 1/10/2024 at 11:40 AM, with Social Worker #1, revealed when a resident has a psychiatric change in diagnoses, the facility receives the diagnosis change from the Psychiatric Nurse Practitioner. At that time, the facility should submit a PASRR Level II change in status request. An interview on 1/10/24 at 12:20 PM, with Social Worker #2, confirmed that Resident #29's last PASRR was completed on 2/13/2014 and she has had two (2) two additional mental health diagnoses, Bipolar II Disorder and Delusional Disorders, since then. She confirmed the facility failed to submit a Level II change in status request for the new mental health diagnoses. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/4/2023 revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact.

Based on observation, staff interviews, record review and facility policy review the facility failed to follow the care plan for one (1) of (14) care plans reviewed. Resident #28. Findings Include: Record review of the facility's policy, Interdisciplinary Care Plan, revision date August 2020, revealed 1. POLICY It is the policy of (Formal Name of Facility) to develop a written individualized care plan that meets the needs and choices of each resident as well as address the strengths, weakness, and goals identified by the resident's assessment,reassessment and results of diagnostic testing. The entire health record should be considered the Plan of Care. 2. PURPOSE The purpose of this policy is to establish measurable guidelines for using the assessments to develop a care plan that meets the resident's needs, choices and addresses their strengths, weaknesses and goals in order to enhance the quality of care provided. Resident #28 On 11/18/21 at 2:40 PM, in an observation of Resident #28, the State Agency (SA) entered resident's room as peri-care was being was being provided by Certified Nursing Assistant #1 (CNA) and assisted by CNA #2. The SA observed a pack of peri wipes lying directly on the bed with no barrier under the wipes. CNA #1 pulled wipes out of the packet and cleaned the resident's buttocks. CNA #1 asked CNA #2 to get the trash the can so she could dispose of the soiled wipes. CNA #2 retrieved a garbage can, while wearing gloves, and placed the garbage can beside the bed. CNA #2 did not remove her gloves and wash her hands after retrieving the garbage can. She returned to Resident #28's side and continued to hold the resident in place. Resident #28 was soiled with feces. CNA #2 pulled the resident over and her gloves became soiled with feces. CNA #2 removed her gloves and put on clean gloves but did not wash her hands. CNA #2 continued to assist CNA #1 by holding the resident in place for care. CNA #1 finished providing peri care to resident's buttocks and placed a clean brief on the resident and began to secure the brief. The SA asked CNA #2 if she had cleaned the vaginal area. CNA #1 then removed resident's brief from the front perineal area and began to wipe the resident's groin area. SA observed resident and noted feces was visible in the groin and vaginal area. CNA #1 did not wash hands or change gloves throughout the entire peri care observation. On 11/18/21 at 4:20 PM, in an interview with CNA #1, she confirmed when she wiped the vaginal and groin area, there was feces in the groin area. CNA #1 stated, I might not have wiped too good. I am supposed to wipe till I see the wipes are clean. CNA #1 said the resident can get an infection from her not changing gloves. She stated the resident can get a [MEDICATION(S)] infection or a Urinary Tract Infection ([CONDITION(S)]) or something like that from the resident not getting good peri care. She stated she did not follow the care plan. On 11/18/21 at 4:35 PM, in an interview with CNA #2 confirmed there was feces on the wipes when CNA #1 wiped the groin area. She stated when she got feces on her gloves, she should have removed gloves, washed her hands, and put on clean gloves. She stated by her not changing gloves and washing her hands, the resident can get an infection and get sick. On 11/19/21 at 9:27 AM, in an interview with RN #3, Minimum Data Set (MDS)/Care Plan Nurse, she stated she wants staff to follow the care plan. She stated the care plan is a blueprint for the care that is to be provided to the resident and by staff not doing care correctly, it could cause the resident to get a [CONDITION(S)], skin breakdown, have discomfort, and in some cases, can cause severe harm to the resident. Record review of the Face Sheet revealed Resident #28 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Care Plan with a Problem Onset date of 1/13/2021, revealed, Resident has potential for skin breakdown, infection, and pain .limited mobility, and incontinence of bowel and bladder. The care plan goal revealed Resident will have no skin breakdown nor infection with multiple protective measures . Care plan approaches included .Check and change per protocol for incontinence-keep clean and dry . Record review of the Quarterly MDS with a Assessment Reference Date (ARD) of 9/20/21, Section C revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #28 was not able to complete the interview. A review of Section G revealed the resident is totally dependent on staff for toilet use and personal hygiene and Section H revealed the resident is always incontinence of bowel and bladder.

Based on observation, staff interview, record review and facility policy review, the facility failed to prevent the possible spread of infection during incontinent care for one (1) of five (5) incontinent care observations. Resident #28. Findings Include: Record review of the facility's policy, Hand Hygiene, with a revision date of March 2021, revealed 1. POLICY It is the policy of (Formal Name of Facility) that employees will use proper hand hygiene techniques to prevent the spread of infectious diseases .PROCEDURE 3. C. Employees must always wash hands: .(8) after removing gloves. (9) After touching objects that may be contaminated with disease causing microorganisms Record review of the facility's policy, Infection Prevention Statement of Purpose, with a Reauthorized date of September 2021, revealed 1. POLICY It is the policy of (formal Name of Facility) to provide comprehensive infection prevention services aimed at surveillance, prevention and control of infections to all Individuals Receiving Services (IRS)/residents, employees, and visitors while always striving to improve quality of care . Record review of the facility's policy, Incontinence Perineal Care with a revised date of October 2020 revealed 1. POLICY It is the policy of (Formal Name of Facility) to provide incontinence/perineal care every two hours and as soiling occurs .3. D. Clean the surface where barrier will be placed with hospital approved disinfectant per manufacturer's recommendations. Apply barrier to surface .G. Female: Starting at the front of the perineal area, wash genital area, moving front to back, separate labia and wash all skin folds . On 11/18/21 at 2:40 PM, in an observation of Resident #28, the State Agency (SA) entered resident's room as peri-care was being was being provided by Certified Nursing Assistant #1 (CNA) and assisted by CNA #2. The SA observed a pack of peri wipes lying directly on the bed with no barrier under the wipes. CNA #1 pulled wipes out of the packet and cleaned the resident's buttocks. CNA #1 asked CNA #2 to get the trash the can so she could dispose of the soiled wipes. CNA #2 retrieved a garbage can, while wearing gloves, and placed the garbage can beside the bed. CNA #2 did not remove her gloves and wash her hands after retrieving the garbage can. She returned to Resident #28's side and continued to hold the resident in place. Resident #28 was soiled with feces. CNA #2 pulled the resident over and her gloves became soiled with feces. CNA #2 removed her gloves and put on clean gloves but did not wash her hands. CNA #2 continued to assist CNA #1 by holding the resident in place for care. CNA #1 finished providing peri care to resident's buttocks and placed a clean brief on the resident and began to secure the brief. The SA asked CNA #2 if she had cleaned the vaginal area. CNA #1 then removed resident's brief from the front perineal area and began to wipe the resident's groin area. SA observed resident and noted feces was visible in the groin and vaginal area. CNA #1 did not wash hand or change gloves throughout the entire peri care observation. On 11/18/21 at 4:20 PM, in an interview with CNA #1, she stated she should have had a barrier in place and that she should have gathered all supplies and put them on a barrier before starting care. She stated the wipes are not supposed to be on the table and not on the bed. She confirmed she should have had the garbage can by the bed and she should have removed her gloves after cleaning the buttocks, washed her hands, and applied clean gloves. She stated she guessed she was not thinking while providing peri care. CNA #1 admitted the resident can get a Urinary Tract Infection ([CONDITION(S)]) from not changing gloves and a [MEDICATION(S)] infection or something like that from resident not getting good peri care. She confirmed when she wiped the vaginal and groin area, there was feces in the groin area. CNA #1 stated, I might not have wiped too good and I am supposed to wipe till I see wipes are clean. CNA #1 said the resident can get an Urinary Tract Infection ([CONDITION(S)]) from her not changing gloves. She stated the resident can get a [MEDICATION(S)] infection or something like that from the resident not getting good peri care. On 11/18/21 at 4:35 PM, in an interview with CNA #2, she stated the CNA's were supposed to have all items on a barrier. She also stated when she gave CNA #1 the garbage can, she did not think about removing her gloves and washing hands. She confirmed that she changed her gloves, but did not wash her hands. She stated when she got feces on her gloves, she should have removed her gloves, washed her hands, and put on clean gloves. She confirmed that by not changing her gloves and washing her hands the resident could get an infection. She confirmed there was feces on the wipes when CNA #1 wiped the groin area. On 11/18/21 at 4:55 PM, in an interview with Registered Nurse #2 (RN)/ Infection Control Nurse, she stated the CNAs placed the resident at risk for infection by placing the pack of wipes on the bed and not providing a barrier. She stated CNA #2 should have washed hands and applied clean gloves after moving the garbage can. She confirmed the actions of the CNAs could cause the resident to get an [CONDITION(S)] or have skin breakdown from not being clean properly. RN #2 confirmed she is responsible for CNA skill check-offs. She stated she completed the skills check-off in October. She stated she completes peri care audits monthly and watches the CNAs provide care to the residents monthly. On 11/18/21 at 5:16 PM, in an interview with Director of Nursing (DON), she stated the CNAs are supposed to have a barrier set up before starting care. and not having a barrier is an infection risk for the resident. She confirmed that CNA #2 should have removed her gloves, washed her hands, and put on clean gloves after she moved the garbage can. She stated by CNA #2 not changing her gloves, the resident can get an infection. She also stated that by CNA #2 not cleaning the resident properly, it could cause the resident to get an [CONDITION(S)] or skin breakdown. The DON confirmed that CNA #1 should have changed her gloves if they were visibly soiled. She stated the CNA should have put down barrier, and pulled all wipes needed out of the pack before starting care and that pulling wipes out pack while cleaning the resident is an infection control issue. On 11/19/21 at 9:27 AM, in an interview with RN #3 Minimum Data Set (MDS)/Care Plan Nurse, she stated by staff not doing care correctly, it could cause the resident to get a [CONDITION(S)], skin breakdown, or have discomfort. On 11/19/21 at 9:32 AM, in an interview with RN #1/Professional Development Nurse/Nurse Educator, she stated the CNAs knew better. She confirmed the CNAs should have had a barrier in place and their actions could cause the resident to have skin breakdown, dignity issues, infection, skin integrity issues and discomfort. Record review of the Face Sheet revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly MDS with a Assessment Reference Date (ARD) of 9/20/21, Section C revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #28 was unable to complete the interview. A review of Section G revealed the resident is totally dependent on staff for toilet use and personal hygiene and Section H revealed the resident is always incontinence of bowel and bladder. Record review of a Staff Development Program Record with the Title of Program listed as Infection Prevention: Focus on Perineal Care dated 10/21/21, revealed CNA #1's signature which confirmed she attended the training. Record review of CNA Annual Competency Check-Off List dated 4/22/21, revealed CNA #1's initials onIncontinent/Perineal Care and Infection Prevention. Record review of CNA Annual Competency Check-Off List dated 8/25/21, revealed CNA #2's initials onIncontinent/Perineal Care and Infection Prevention. Record review of CNA Skills Checklist dated 8/25/21 .SKILL . Male and Female Pericare/Incontinent Care revealed CNA #1's signature dated 4/21/21 and initials under the met column.

Based on interview, record review, and policy review, the facility failed to ensure Resident #1 was free from neglect, as evidenced by, staff failed to check the meal ticket and actual diet to ensure correct texture and consistency was provided for one (1) of four (4) residents reviewed, of 39 residents who received mechanically altered diets. The facility staff also acted in a dishonest manner in an attempt to make it appear Resident #1 received the correct diet, by switching meal tickets. An Immediate Jeopardy (IJ) was determined to exist when the facility neglected to serve Resident #1 a Mechanical Soft Diet with Chopped Meats, as ordered. On [DATE] at approximately 12:10 PM, Resident #1 was served a Regular Diet with sliced turkey (not chopped) and at approximately 12:15 PM, the resident became choked on the turkey. The facility staff performed the [MEDICATION NAME] maneuver, and began Cardiopulmonary Resuscitation (CPR), until the resident was transported to a local hospital emergency room (ER). Resident #1 was placed in the Intensive Care Unit (ICU) on a ventilator and expired on [DATE], as a result of the choking episode and [MEDICAL CONDITION]. The facility's failure on [DATE], to serve Resident #1 the correct diet consistency/texture of a Mechanical Soft Diet with Chopped Meats, as ordered, caused the resident to choke, and subsequently expire. This placed other residents with mechanically altered diets in a situation that was likely to cause serious harm, injury, impairment or death. Based on the facility's implementation of corrective actions as of [DATE], prior to the State Agency's (SA) entrance on [DATE], the SA determined the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) to be Past Non-Compliance (PNC) and the IJ was removed as of [DATE]. The SA notified the Administrator of the PNC IJ and SQC on [DATE] at 3:30 PM. Findings Include: Review of the Suspicion of Abuse, Neglect, Exploitation and/or Injuries of Unknown Origin to Individuals Receiving Services policy, revised (MONTH) 2019, revealed: Neglect is the failure to supply an Individual Receiving Services (IRS) with food, shelter, clothing, or other services necessary to maintain physical and mental health. All employees will immediately report witnessing of or discovery of any situation in which suspicion exists that an IRS has been the victim of neglect. Review of Special Food Services Protocol: Therapeutic Programming Snack and Special Event (Protocol ,[DATE]), dated (MONTH) 2013, revealed: Staff will identify the resident, prior to serving food, by viewing the resident identification bracelet. Staff assisting with meal service will be familiar with special diet considerations, which are part of the Physicians Order List (POL). This includes identification of food consistency required by any listed diet and any special considerations. If the POL is not present in the dining room, then NO food or beverage may be offered until the list is available and checked for reference. Review of the Food Service Duties: (Quick Reference), dated (MONTH) 2013, revealed: The Nurse must check the POL with the meal service ticket, and the Certified Nursing Assistant (CNA) must check the identification bracelet. Both the Nurse and CNA must check the basic diet and consistency of food, prior to serving the diet/tray to the resident. Review of Resident #1's medical record revealed a physician's orders [REDACTED]. Speech Therapy treated Resident #1 for the [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on [DATE], with a continued [DIAGNOSES REDACTED]. Review of the facility's Investigative Summary Report, dated [DATE], revealed Resident #1 choked after eating a Regular diet tray, which contained a slice of whole turkey. Resident #1 was ordered a Mechanical Soft Diet with Chopped Meat. Abdominal thrusts were performed. Resident #1 became unresponsive and was lowered to the floor. CPR was initiated. Resident #1 was noted to be in respiratory distress from choking. Resident #1 was transferred to the local hospital for further medical treatment. The Investigative Report revealed, CNAs #1, #2, #3 and RN #1, violated established facility Protocol #,[DATE], which included not checking for proper resident identification and ordered diet. These staff also switched meal tickets between Resident #1 and #2 to make it appear Resident #1 received the right diet. These staff were suspended and terminated for the violations. The report included a section titled, Accident/Incident Type which documented, Resident #1's death was a result of staff negligence/procedural violation. An interview with the Director of Nursing (DON), on [DATE] at 10:30 AM, confirmed CNAs #1, #2, #3 and RN #1, had been trained on Diet and Tray Service and Abuse/Neglect, but chose to be dishonest and not follow the protocol, and they knew better. They switched the diet sheets and names off of the meal trays for Resident #1. The DON stated Resident #1's choking incident was recorded via video cameras and uncovered the dishonest acts of the staff. During an interview on [DATE] at 11:00 AM, the Administrator confirmed a photograph of Resident #1's meal tray and ticket, was taken by Speech Therapist #2 on [DATE]. Review of the photograph, identified what appeared to be a piece of unchopped meat on Resident #1's meal tray. In the photograph, Resident #1's meal ticket was sitting beside the tray, which documented: one-half (,[DATE]) cup chopped turkey with gravy. The meal ticket did not match what was identified on the tray for Resident #1's noon meal. During an interview and review of video footage with the Administrator on [DATE] at 11:00 AM and again at 4:30 PM, the Administrator confirmed Resident #1 had been served unchopped turkey at the noon meal on [DATE]. Resident #1 choked on the unchopped turkey and expired at the local hospital on [DATE], as a result of receiving the wrong diet. The Administrator stated he and Licensed Practical Nurse (LPN) #1/Facility Investigator, reviewed the video of the choking incident and discovered four (4) staff, Certified Nursing Assistants (CNAs) #1, #2, #3 and Registered Nurse (RN) #1, failed to verify and serve the appropriate diet to the resident. The video revealed all three (3) CNAs left Resident #1 with the meal tray and the Resident began to cram large amounts of the turkey in her mouth, without swallowing/rests between bites, and she began to choke. The Administrator stated staff attempted to cover up the choking incident, by switching the meal tickets to make it appear Resident #1 received the correct diet and they knew better. In an interview on [DATE] at 11:15 AM with Licensed Practical Nurse (LPN) #1/Investigator, revealed he had done a complete investigation of all of the events and found that staff members, CNAs (CNA #1, CNA #2, & CNA #3) and Registered Nurse (RN#1), were responsible for the wrong diet being served to Resident #1 on [DATE], at the noon meal. LPN #1 stated the four (4) staff had not been truthful about the events of the incident on [DATE] of Resident #1's choking. CNA #1 and #3 switched the tray tickets to indicate Resident #1 and #2 had received the correct diet. Resident #2 was to have received a Regular Diet, but instead received a Mechanical Soft Diet meant for Resident #1. CNA #1 served Resident #1 the Regular Diet meant for Resident #2. LPN #1 confirmed the four (4) staff involved were negligent on the procedure for following the established Food Service protocol for serving food trays to the residents in the dining room. LPN #1 stated the four (4) staff involved in the choking incident of Resident #1, on [DATE], knew better and they did not follow the training they had been given. Interview on [DATE] at 11:20 AM, with the Director of the Rehabilitation Department and Speech Therapist (ST) #2, confirmed ST #2 observed Resident #1 choking and she took a photo of the tray Resident #1 had been eating prior to choking on [DATE]. The Director of the Rehabilitation Department, confirmed Resident #1 was served the wrong diet texture and wrong diet consistency at the noon meal on [DATE], that resulted in Resident #1's choking and ultimate death. During an interview on [DATE] at 12:00 PM, the facility's Educator, Registered Nurse (RN) #2, confirmed all staff are trained and were aware of the policies and procedures for Abuse and Neglect and on the Food Service Duties: (Quick Reference). RN #2 stated all four (4) staff, (CNA #1, #2, #3 and RN #1), involved in the choking incident of Resident #1, on [DATE], had knowledge of the POL, which included Resident #1's diet of Mechanical Soft with Chopped Meat, and failed to follow the policies and procedures. Review of a typed statement, undated, revealed RN #2 documented new employees are educated on how to read a meal ticket, how to pass trays out to residents to verify the correct meal is what is on the plate, and following the Care Guide (Care Plan). She documented failure to follow this process is Abuse/Neglect. In an interview with the Quality Assurance (QA) Nurse on [DATE] at 10:30 AM, revealed the QA Committee met on [DATE] at 4:00 PM, and reviewed the choking incident of Resident #1, along with policies and procedures of Abuse/ Neglect, Care Plans, Safe Service of Diets, Accidents Hazards and reporting incidents. The QA Committee determined the failure to follow the established procedures to ensure residents were served the right diet caused Resident #1 to choke and subsequently expire. The dishonest switching of the food tray tickets by the CNAs and the failure to serve the correct diet, was considered a result of staff negligence. During an interview, on [DATE] at 10:50 AM, the Care Plan Nurse Coordinator/Registered Nurse (RN) #5, revealed Resident #1 has been ordered a Mechanical Soft Diet with Chopped Meats, on [DATE]. RN #5 confirmed the POL dated [DATE], did document Mechanical Soft Diet with Chopped Meats for Resident #1. RN #5 confirmed the POL was printed and distributed daily to the dietary department and to each of the nursing stations. RN #5 stated the POL is used to check the food trays against the food tickets for each resident's food tray. RN #5 verified the RN assigned (RN #1) to the dining room was responsible for checking the POLs and the food tickets prior to the CNAs serving the food trays. RN #5 stated the order/care plan for Resident #1 was not followed on [DATE], which resulted in the choking of Resident #1. The negligent action by RN #1 of not checking Resident #1's diet, prior to serving, and CNA #1 serving the resident the wrong diet, resulted in the resident's death. On [DATE] at 1:15 PM, an attempt was made to contact CNA #3 by phone without success. Review of a documented statement by CNA #3, dated [DATE] at 4:23 PM, revealed Resident #2 was observed eating food from a meal tray with Resident #1's name on the ticket. CNA #3 documented she checked the meal tray, served to Resident #1 by CNA #1, which had dressing, roll and turkey. CNA #3 documented, give me the ticket. On [DATE] at 1:20 PM, an attempt was made by phone to contact CNA #1 without success. Review of a documented statement by CNA #1, dated [DATE] at 2:07 PM, revealed she confirmed Resident #2 ate Resident #1's noon meal tray on [DATE], and she gave Resident #1 the meal tray, which belonged to Resident #2. The statement documented, RN #1 opened the lid of Resident #2's tray, stated it was the same food, and instructed CNA #1 to give the meal tray to Resident #1. CNA #1 documented, I did what I was told and put the tickets with the tray. In an interview by phone, on [DATE] at 2:50 PM, RN #1 confirmed she checked the food tray tickets against the physician's orders [REDACTED].#1 stated she learned how to check the food tray tickets against the POL by other nurses passing the information to her in reports. She stated she had never been trained on the procedure of checking food trays against the POL and/or serving meal trays. RN #1 stated she did pass out trays and did not hand trays to CNAs. RN #1 stated she never told CNA #1 to serve Resident #1 the food tray of Resident #2; she told CNA #1 to give Resident #1 another tray that was the same diet, which was Mechanical Soft with Chopped Meats. RN #1 stated she resigned her position at the facility. Review of the facility's individual training records and documented in-services revealed, all three (3) CNAs and RN #1 were in-serviced on Abuse/Neglect, New Employee Orientation, Meal and Hydration, Serving Meals in the Dining Room and Armband Checks prior to the choking incident of Resident #1. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan/Corrective Actions, prior to the State Agency (SA) entrance on [DATE]. In response to the Immediate Jeopardy (IJ) that was cited at 3:30 PM on [DATE], the facility submitted a brief summary of the event, including an IJ Removal Plan and Corrective Actions, taken by the facility, to remove the Immediate Jeopardy (IJ): 1. Description Of Incident: Resident #1 was a [AGE] year old white female, admitted to the facility, on (MONTH) 24, 2019. Resident #1 had an admitting [DIAGNOSES REDACTED]. Resident #1 was admitted on a Regular Diet with No Corn, due to allergies [REDACTED].#1's diet was changed, by the physician, from a Regular Diet to a Mechanical Soft with Chopped Meat Diet, due to having a choking episode while eating peaches. On (MONTH) 24, 2019 at 12:15 PM, Resident #1 choked, while eating lunch in the dining room, due to receiving a Regular Diet, instead of a Mechanical Soft with Chopped Meat Diet, as ordered by the physician, and the care plan. Resident #1 passed away, on (MONTH) 27, 2019 at 9:15 AM, at the local hospital, due to [MEDICAL CONDITION]/[MEDICAL CONDITION], per local hospital records. 2. The facility's Hospital Director and Nursing Home Administrator were notified of the incident on (MONTH) 24, 2019 at 12:30 PM, by the facility's Dietary Manager. The Hospital Director gave directives to refer the incident to Investigative Services and the Quality Assurance Department. Investigative Services arrived at the facility and began an investigation of the incident on (MONTH) 24, 2019 at 12:55 PM. 3. Measures Implemented: The Quality Assurance (QA) Committee held an Emergency QA Meeting on (MONTH) 24, 2019 at 4:00 PM, with the following staff: Nursing Home Administrator, Nurse Manager, Medical Nurse Practitioner (Representing the Medical Director), Minimum Data Set (MDS) Coordinator, Contract Rehab Director, Nurse Supervisor, QA Nurse, and Investigator. The QA Committee reviewed the Abuse, Neglect and Exploitation Policy, discussed Accidents and Hazards; the QA Committee did not recommend any changes at this time. The QA Committee also reviewed the Food Service Duties Quick Reference and Resident #1's Care Plan. The QA Committee found that RN #1 and CNAs #1, #2 and #3 failed to follow the Food Service Duties Quick Reference, which resulted in Resident #1 receiving a Regular Diet, instead of a Mechanical Soft with Chopped Meat Diet, that was ordered by the physician, and noted on the care plan. The QA Committee recommended to immediately begin training all staff on following the Food Service Duties Quick Reference and following residents diets as care planned, to prevent accidents and hazards. The QA Committee recommended all staff on duty be trained before the next meal was served. The QA Committee also recommended that RN #1 and CNAs #1, #2, and #3 be placed on Administrative Leave, for serving Resident #1 the wrong diet, and not following policy and procedure. The QA Committee identified 39 of 101 residents, who were on mechanically altered diets, had the potential to be affected, by receiving an incorrect diet. On (MONTH) 24, 2019 at 5:00 PM, the Quality Assurance Nurse performed chart audits of the 39 residents, who had the potential to be affected, and found that no changes were needed. 4. Training/In-services: On (MONTH) 24, 2019 at 4:30 PM, the Nurse Supervisor began in-services on the Food Service Duties Quick Reference procedures for passing out meal trays with all staff. All staff working were trained prior to the next meal being served. The Nurse Supervisor began training for the oncoming night shift employees at 6:30 PM. On (MONTH) 25, 2019 at 6:30 AM, all oncoming staff were trained by the Nurse Supervisor before starting the shift. On (MONTH) 25, 2019 at 6:30 PM, all oncoming staff were trained by the Nurse Supervisor before starting the shift. All In-services were completed by (MONTH) 25, 2019 at 7:00 PM. Any staff that did not receive this training will be trained immediately upon returning to work. The following In-services covered: Accidents and Hazards and Supervision - All staff were trained on the Nurse checking the Physician order [REDACTED]. If supervision is not carried out it could result in a hazard and/or accident. Abuse/Neglect - All staff were trained on how to check the diet to ensure the correct diet consistency is on each meal tray for that particular resident per the Physicians Order List (POL). Diet - All staff were trained on the Nurse checking the Physicians Order List (POL) with the tray ticket for correct diet consistency, and whoever delivers the tray to the resident, must remove the lid from the tray to check the consistency of the food on the tray to the meal ticket. Care Plan - All staff were trained on each individual resident's diet consistency that is listed on the Physicians Order List (POL), which reflects the resident's Plan of Care. 5. All staff, including new hires, will receive training on food service prior to being able to work. 6. Disciplinary Actions: On (MONTH) 24, 2019, after the investigation was initiated, it was determined there was enough evidence to place CNAs #1, #2, #3 and RN #1 on administrative leave pending completion of the investigation. RN #1 resigned from employment on (MONTH) 25, 2019. CNA #1 was terminated from employment effective (MONTH) 31, 2019. CNA #2 was terminated from employment effective (MONTH) 30, 2019. CNA #3 was terminated from employment effective (MONTH) 30, 2019. 7. Notification of State Agencies: On (MONTH) 24, 2019 at 4:52 PM, the facility's Investigator notified the Mississippi State Department of Health (MSDH) by telephone. On (MONTH) 25, 2019 at 9:20 AM, the facility's Investigator notified The Mississippi Attorney General's Office in writing of the incident. 8. Removal of Immediate Jeopardy: All activities to remove the Immediate Jeopardy were accomplished on (MONTH) 25, 2019, and the facility alleges that the removal of the Immediate Jeopardy was effective as of (MONTH) 26, 2019. The State Agency (SA) validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observation, interview, and facility record review. 1. The SA validated through record review, staff interview, and video tape review of the incident, on [DATE], of Resident #1 choking in the dining room during the noon meal. The SA surveyor watched the video along with the facility Administrator. The SA validated Resident #1 had an order for [REDACTED].#1 was transferred to the hospital after a choking episode from the incorrect diet. Resident #1 expired on [DATE], related to the incident. 2. The SA validated the facility began an investigation of the choking incident on [DATE], after notification to the Administrator. 3. The SA validated the Quality Assurance (QA) signature sheets and documentation of the QA meeting, that was held on [DATE]. Interviews with the facility Administrator and QA Nurse/RN #4, validated the QA meeting of [DATE]. Interviews with the Director of Nursing (DON), the Minimum Data Set (MDS) Care Plan Coordinator/RN#5, and the QA Nurse/RN #4 validated that the orders and care plans of the 39 residents who had mechanically altered diets, were audited with no changes. The QA meeting included recommendations for training of staff for following resident's diets, as care planned, to prevent accidents and hazards. The SA interviewed the QA Nurse on [DATE], and validated the signature sheets and the topics discussed in the QA meeting. The QA Nurse confirmed some of the topics discussed in the QA meeting were Abuse and Neglect; Care Plans, Residents Diets and Service of Diets, Safety of Residents, and Prevention of Accidents. The QA Nurse stated the QA members made no further recommendations and determined there were four (4) staff members responsible for the noon meal of Resident #1, and on [DATE], they made the choice not to follow the established policies and procedures. The QA Nurse stated these four (4) staff neglected to follow the established policies and procedures and their choice caused Resident #1 to choke. 4. The SA reviewed the signature sheets for the training, which began on [DATE] and ended on [DATE]. The SA validated the in-services contained training on Abuse and Neglect, Safety, Residents Mechanically Altered Diets, Meal Service and Safety, Checking the Physician order [REDACTED]. Interviews and record reviews validated all staff had been in-serviced on their duty to monitor the dining room, provide the ordered diet, supervision of residents, abuse/neglect and care plans. During the survey, licensed nurses were observed in the dining room monitoring the meals of the residents, per policy and protocol. The facility provided documentation of training topics given to all staff on [DATE] and [DATE]. Copies of the training and the signature sheets were provided to the SA for validation. Interviews with licensed nursing staff, Food Service staff, Administrative staff, and Certified Nursing Assistant (CNA) staff, validated all staff working in the facility had been in-serviced on their duty to serve, check, cue, supervise, and monitor the residents for all meals, and knew the facility's policies and procedures for abuse and neglect. 5. The SA validated no staff worked prior to training of the Food Service Protocol and in-services. 6. The SA validated CNA #1, #2, #3 and RN #1 were suspended on [DATE], and are no longer employed by the facility. 7. The SA validated all appropriate State agencies were notified of the choking incident for Resident #1. 8. The SA accepted the facility's Removal Plan and determined all corrective actions were completed on [DATE], and the IJ was removed on [DATE], prior to the SA entrance on [DATE].

Based on observation, interview, record review, and policy and procedure review, the facility failed to ensure an individual care plan was implemented for a Mechanical Soft Diet with Chopped Meats for one (1) of four (4) sampled residents, of 39 residents, with mechanically altered diets, Resident #1. An Immediate Jeopardy (IJ) was determined to exist on [DATE], when Resident #1 was served a Regular Diet, and was ordered and care planned to receive a Mechanical Soft Diet with Chopped Meats. On [DATE], during the noon meal, Resident #1 choked after eating a diet with the wrong texture and wrong consistency (whole piece of turkey), served by the facility staff. Resident #1 suffered a Cardiopulmonary Arrest on [DATE], and died at a local hospital on [DATE], as a result of the choking incident. The staff did not follow the established individual care plan of Resident #1, which resulted in the death of Resident #1. The facility's failure to follow the individual comprehensive care plan for Resident #1, resulted in the choking of Resident #1 and ultimately lead to her death and placed other residents, care planned with mechanically altered diets, in a situation that was likely to cause serious harm, injury, impairment, or death. Based on the facility's implementation of the IJ Removal Plan/ Corrective Actions as of [DATE], the SA determined the IJ was Past Non-Compliance (PNC) and the IJ was removed as of [DATE], prior to the SA entrance on [DATE]. The SA notified the Administrator of the PNC IJ and SQC on [DATE] at 3:30 PM. Findings Include: Review of the facility's Interdisciplinary Care Plan policy, revised (MONTH) (YEAR), revealed, it is the policy of the facility to develop a written individualized care plan that meets the needs and choices of each resident as well as address the strengths, weaknesses and goals identified by the resident's assessment, reassessment and results of diagnostic testing. The entire health record should be considered the plan of care. Care will be provided as planned. Appropriate considerations and monitoring of factors that commonly contributes to the health and well-being of residents over the course of treatment, including but not limited to: Nutrition and hydration requirements. A Daily Care Guide to educate the Certified Nurse Assistants (CNAs) regarding necessary interventions will be provided to the CNAs responsible for the resident's care. Record review of Resident #1's individual Comprehensive Care Plan, revealed Resident #1 had a care plan revised on [DATE] to indicate Mechanical Soft diet with chopped meats. No corn products. Staff to cue and assist with meals and snacks and monitor for adequate chewing before swallowing. The care plan designated this role to Nursing staff. Further review of the care plan for Resident #1 revealed, a revision was documented on [DATE], Mechanical Soft Diet with chopped meats and no fresh corn. Review of a Speech Therapy (ST) evaluation and Care Plan for Resident #1, dated [DATE], revealed ST treatments for Dysphagia. Record review of Resident #1's (MONTH) 2019 physician's orders [REDACTED]. Review of an investigative report, dated [DATE], revealed Resident #1 was served a Regular Diet, which included a slice of whole turkey, instead of a Mechanical Soft Diet with Chopped Meats, as care planned. Resident #1 choked, became unresponsive, and Cardiopulmonary Resuscitation (CPR) was initiated. Resident #1 was transferred to the hospital, admitted to the Intensive Care Unit (ICU) on a ventilator, and subsequently expired on [DATE], related to the choking incident. Interview on [DATE] at 10:50 AM, with the Care Plan Nurse Coordinator/Registered Nurse (RN) #5, revealed the care plans are coordinated in conjunction with the Minimum Data Set (MDS) and Resident #1 had been care planned on [DATE] for Mechanical Soft Diet with Chopped Meats. RN #5 verified the RN assigned to the dining room was responsible for checking the diet orders and the food tickets prior to the CNAs serving the food trays. RN #5 stated the care plan for Resident #1 was not followed, as she did not receive chopped meats, on [DATE], which resulted in the choking of Resident #1. During an interview on [DATE] at 3:00 PM, the Registered Dietician (RD), confirmed he had been a part of the team that developed Resident #1's care plan. The RD confirmed the care plan for Resident #1 was not followed during the lunch meal on [DATE], and resulted in the choking of Resident #1. RD confirmed Resident #1 was to have received a Mechanical Soft Diet with Chopped Meats, and instead she had received a Regular Diet on [DATE], during the noon meal. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan/Corrective Actions, prior to the State Agency (SA) entrance on [DATE]. In response to the Immediate Jeopardy (IJ) that was cited at 3:30 PM on [DATE], the facility submitted a brief summary of the event, including an IJ Removal Plan and Corrective Actions, taken by the facility, to remove the Immediate Jeopardy (IJ): 1. Description Of Incident: Resident #1 was a [AGE] year old white female, admitted to the facility, on (MONTH) 24, 2019. Resident #1 had an admitting [DIAGNOSES REDACTED]. Resident #1 was admitted on a Regular Diet with No Corn, due to allergies [REDACTED].#1's diet was changed, by the physician, from a Regular Diet to a Mechanical Soft with Chopped Meat Diet, due to having a choking episode while eating peaches. On (MONTH) 24, 2019 at 12:15 PM, Resident #1 choked, while eating lunch in the dining room, due to receiving a Regular Diet, instead of a Mechanical Soft with Chopped Meat Diet, as ordered by the physician, and the care plan. Resident #1 passed away, on (MONTH) 27, 2019 at 9:15 AM, at the local hospital, due to [MEDICAL CONDITION]/[MEDICAL CONDITION], per local hospital records. 2. The facility's Hospital Director and Nursing Home Administrator were notified of the incident on (MONTH) 24, 2019 at 12:30 PM, by the facility's Dietary Manager. The Hospital Director gave directives to refer the incident to Investigative Services and the Quality Assurance Department. Investigative Services arrived at the facility and began an investigation of the incident on (MONTH) 24, 2019 at 12:55 PM. 3. Measures Implemented: The Quality Assurance (QA) Committee held an Emergency QA Meeting on (MONTH) 24, 2019 at 4:00 PM, with the following staff: Nursing Home Administrator, Nurse Manager, Medical Nurse Practitioner (Representing the Medical Director), Minimum Data Set (MDS) Coordinator, Contract Rehab Director, Nurse Supervisor, QA Nurse, and Investigator. The QA Committee reviewed the Abuse, Neglect and Exploitation Policy, discussed Accidents and Hazards; the QA Committee did not recommend any changes at this time. The QA Committee also reviewed the Food Service Duties Quick Reference and Resident #1's Care Plan. The QA Committee found that RN #1 and CNAs #1, #2 and #3 failed to follow the Food Service Duties Quick Reference, which resulted in Resident #1 receiving a Regular Diet, instead of a Mechanical Soft with Chopped Meat Diet, that was ordered by the physician, and noted on the care plan. The QA Committee recommended to immediately begin training all staff on following the Food Service Duties Quick Reference and following residents diets as care planned, to prevent accidents and hazards. The QA Committee recommended all staff on duty be trained before the next meal was served. The QA Committee also recommended that RN #1 and CNAs #1, #2, and #3 be placed on Administrative Leave, for serving Resident #1 the wrong diet, and not following policy and procedure. The QA Committee identified 39 of 101 residents, who were on mechanically altered diets, had the potential to be affected, by receiving an incorrect diet. On (MONTH) 24, 2019 at 5:00 PM, the Quality Assurance Nurse performed chart audits of the 39 residents, who had the potential to be affected, and found that no changes were needed. 4. Training/In-services: On (MONTH) 24, 2019 at 4:30 PM, the Nurse Supervisor began in-services on the Food Service Duties Quick Reference procedures for passing out meal trays with all staff. All staff working were trained prior to the next meal being served. The Nurse Supervisor began training for the oncoming night shift employees at 6:30 PM. On (MONTH) 25, 2019 at 6:30 AM, all oncoming staff were trained by the Nurse Supervisor before starting the shift. On (MONTH) 25, 2019 at 6:30 PM, all oncoming staff were trained by the Nurse Supervisor before starting the shift. All In-services were completed by (MONTH) 25, 2019 at 7:00 PM. Any staff that did not receive this training will be trained immediately upon returning to work. The following In-services covered: Accidents and Hazards and Supervision - All staff were trained on the Nurse checking the Physician order [REDACTED]. If supervision is not carried out it could result in a hazard and/or accident. Abuse/Neglect - All staff were trained on how to check the diet to ensure the correct diet consistency is on each meal tray for that particular resident per the Physicians Order List (POL). Diet - All staff were trained on the Nurse checking the Physicians Order List (POL) with the tray ticket for correct diet consistency, and whoever delivers the tray to the resident, must remove the lid from the tray to check the consistency of the food on the tray to the meal ticket. Care Plan - All staff were trained on each individual resident's diet consistency that is listed on the Physicians Order List (POL), which reflects the resident's Plan of Care. 5. All staff, including new hires, will receive training on food service prior to being able to work. 6. Disciplinary Actions: On (MONTH) 24, 2019, after the investigation was initiated, it was determined there was enough evidence to place CNAs #1, #2, #3 and RN #1 on administrative leave pending completion of the investigation. RN #1 resigned from employment on (MONTH) 25, 2019. CNA #1 was terminated from employment effective (MONTH) 31, 2019. CNA #2 was terminated from employment effective (MONTH) 30, 2019. CNA #3 was terminated from employment effective (MONTH) 30, 2019. 7. Notification of State Agencies: On (MONTH) 24, 2019 at 4:52 PM, the facility's Investigator notified the Mississippi State Department of Health (MSDH) by telephone. On (MONTH) 25, 2019 at 9:20 AM, the facility's Investigator notified The Mississippi Attorney General's Office in writing of the incident. 8. Removal of Immediate Jeopardy: All activities to remove the Immediate Jeopardy were accomplished on (MONTH) 25, 2019, and the facility alleges that the removal of the Immediate Jeopardy was effective as of (MONTH) 26, 2019. The State Agency (SA) validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observation, interview, and facility record review. 1. The SA validated through record review, staff interview, and video tape review of the incident, on [DATE], of Resident #1 choking in the dining room during the noon meal. The SA surveyor watched the video along with the facility Administrator. The SA validated Resident #1 had an order for [REDACTED].#1 was transferred to the hospital after a choking episode from the incorrect diet. Resident #1 expired on [DATE], related to the incident. 2. The SA validated the facility began an investigation of the choking incident on [DATE], after notification to the Administrator. 3. The SA validated the Quality Assurance (QA) signature sheets and documentation of the QA meeting, that was held on [DATE]. Interviews with the facility Administrator and QA Nurse/RN #4, validated the QA meeting of [DATE]. Interviews with the Director of Nursing (DON), the Minimum Data Set (MDS) Care Plan Coordinator/RN#5, and the QA Nurse/RN #4 validated that the orders and care plans of the 39 residents who had mechanically altered diets, were audited with no changes. The QA meeting included recommendations for training of staff for following resident's diets, as care planned, to prevent accidents and hazards. The SA interviewed the QA Nurse on [DATE], and validated the signature sheets and the topics discussed in the QA meeting. The QA Nurse confirmed some of the topics discussed in the QA meeting were Abuse and Neglect; Care Plans, Residents Diets and Service of Diets, Safety of Residents, and Prevention of Accidents. The QA Nurse stated the QA members made no further recommendations and determined there were four (4) staff members responsible for the noon meal of Resident #1, and on [DATE], they made the choice not to follow the established policies and procedures. The QA Nurse stated these four (4) staff neglected to follow the established policies and procedures and their choice caused Resident #1 to choke. 4. The SA reviewed the signature sheets for the training, which began on [DATE] and ended on [DATE]. The SA validated the in-services contained training on Abuse and Neglect, Safety, Residents Mechanically Altered Diets, Meal Service and Safety, Checking the Physician order [REDACTED]. Interviews and record reviews validated all staff had been in-serviced on their duty to monitor the dining room, provide the ordered diet, supervision of residents, abuse/neglect and care plans. During the survey, licensed nurses were observed in the dining room monitoring the meals of the residents, per policy and protocol. The facility provided documentation of training topics given to all staff on [DATE] and [DATE]. Copies of the training and the signature sheets were provided to the SA for validation. Interviews with licensed nursing staff, Food Service staff, Administrative staff, and Certified Nursing Assistant (CNA) staff, validated all staff working in the facility had been in-serviced on their duty to serve, check, cue, supervise, and monitor the residents for all meals, and knew the facility's policies and procedures for abuse and neglect. 5. The SA validated no staff worked prior to training of the Food Service Protocol and in-services. 6. The SA validated CNA #1, #2, #3 and RN #1 were suspended on [DATE], and are no longer employed by the facility. 7. The SA validated all appropriate State agencies were notified of the choking incident for Resident #1. 8. The SA accepted the facility's Removal Plan and determined all corrective actions were completed on [DATE], and the IJ was removed on [DATE], prior to the SA entrance on [DATE].

Based on observation, interview, record review, and facility policy and procedure review, the facility failed to provide residents with the supervision, required and needed, to prevent accidents, hazards, choking, injury, and death, during meal consumption, for one (1) of four (4) sampled residents, of 39 residents, with physician orders [REDACTED].#1. Resident #1 had a physician's orders [REDACTED]. On [DATE], during the noon meal, Certified Nursing Assistant (CNA) #1 served Resident #1 a whole piece of sliced turkey, instead of chopped turkey, and the resident choked on the meat. Resident #1 was sent to the hospital, placed on a ventilator, and expired on [DATE], related to the incident. Registered Nurse (RN) #1 was assigned to the dining room, and failed to supervise the meal service to ensure staff provided Resident #1 with the correct diet. The facility's failure to provide supervision during meal service, to ensure the correct diet was served, led to Resident #1's death and placed other residents with mechanically altered diets in a situation that was likely to cause serious harm, injury, impairment or death. Based on the facility's implementation of an Immediate Jeopardy (IJ) Removal Plan and Corrective Actions, as of [DATE], prior to the State Agency (SA) entrance on [DATE], the SA determined the IJ and the Substandard Quality of Care (SQC) was Past Non-Compliance (PNC) and the IJ was removed as of [DATE]. The SA notified the Administrator of the PNC IJ and SQC on [DATE] at 3:30 PM. Findings Include: Review of the facility's Special Food Services Protocol: Therapeutic Programming Snack and Special Event (Protocol ,[DATE]), dated (MONTH) 2013, revealed the Physicians Order List (POL) will be utilized to verify food consistency. The POL is provided to each nurses and is updated daily. The POL is checked for reference prior to serving any food. Staff assisting with meal service will be familiar with special diet consideration, which includes identification of food consistency, required by any listed diet. Review of the facility's Food Service Duties (Quick Reference)policy and procedure, dated (MONTH) 2013, revealed: Dining Room (Anytime Food Is Served) 2. NURSE ONLY checks Physician order [REDACTED]. Check ,[DATE] trays at a time. Check ticket ONLY for basic diet and food/beverages consistency with the POL, if discrepancy, notify the Unit Nurse to check the physician's orders [REDACTED]. 3. CNAs or staff assigned to Dining Room Duty that day, will serve trays after the nurse checks the ticket. When the tray is taken to the resident, check the ticket with the resident's identification arm band. If the resident has no arm band, ask the nurse in the dining room area to verify the resident and consistency on the POL, and serve food. Check basic diet and food/beverage consistency on tray ticket with the food on the tray. If there is a discrepancy, notify the kitchen staff the food is not correct. Record review of the facility's Investigative Summary Report, dated [DATE], revealed: Accident/Incident Type: Resident death (as a result of staff negligence/procedural violation). Resident #1 became choked after being served and eating a Regular Diet with whole meat, instead of the mechanically altered diet with Chopped Meats, during the noon meal on [DATE]. Abdominal thrusts were performed, resident became unresponsive, and Cardiopulmonary Resuscitation (CPR) was initiated. Resident #1 was transferred by ambulance to the local hospital, where she was admitted to the Intensive Care Unit (ICU) and placed on a ventilator, and subsequently expired on [DATE], related to the choking incident. The investigation revealed, Resident #1 was served and was eating a slice of whole turkey, instead of chopped turkey, when she became choked. Resident #1 was served the Regular Diet tray by Certified Nursing Assistant (CNA) #1. The sequence of events involving the wrong diet being served to Resident #1, started when CNA #2 placed Resident #1's correct meal tray on a table unattended (Resident #1 was not present), and Resident #2 ate Resident #1's meal. About the time Resident #2 was finished eating the meal, CNA #1 noticed Resident #2 had consumed Resident #1's meal. Once Resident #1 arrived in the dining room, CNA #1 informed RN #1 of Resident #2 eating Resident #1's meal. CNA #1 stated the RN opened the lid on a tray (Resident #2's tray), still on the cart, and stated, It's the same food, and instructed her to give the tray to Resident #1, which was a Regular Diet and contained a slice of whole turkey. CNA #1 and CNA #3 swapped the meal tickets to make it appear Resident #1 received the correct meal tray. The investigation revealed, RN #1 stated her instructions to CNA #1, was to see if Resident #2 was on the same diet as Resident #1, and did not follow up regarding the diets. CNA #1, #2, #3 and RN #1, were placed on administrative leave pending investigation. Review of a prior Accident and Incident (A&I) Report Form, dated [DATE], revealed Resident #1 had a choking incident, which required the [MEDICATION NAME] maneuver to expel food. This resulted in a diet change from a Regular Diet to Mechanical Soft with Chopped Meats. Review of Resident #1's medical record revealed the (MONTH) 2019 physician's orders [REDACTED].#1 to have a Mechanical Soft Diet with Chopped Meats. During an interview, on [DATE] at 11:20 AM, the Speech Therapist (ST) #1 revealed, she made a recommendation on [DATE], for Resident #1 to have a Mechanical Soft Diet with Chopped Meats due to her rate issues with eating foods, which made her a choking risk. The ST confirmed the physician wrote an order for [REDACTED]. Review of the tray ticket, from [DATE], for Resident #1, revealed one-half (,[DATE]) cup Chopped Turkey with Gravy. Review of a photograph (verified as taken by ST #2), of the meal tray served to Resident #1 on [DATE], revealed a partially-eaten slice of whole meat, instead of chopped meats as ordered. Review of the physician's orders [REDACTED].#1 was to receive a Mechanical Soft Diet with Chopped Meats. During an interview with Licensed Practical Nurse (LPN) #1/Facility Investigator, on [DATE] at 11:15 AM, confirmed Resident #1 received the wrong diet on [DATE], choked, and subsequently expired on [DATE]. LPN #1 confirmed the four (4) staff, CNA #1, #2, #3 and RN #1, violated Protocol ,[DATE] (Special Food Services Protocol), when they did not supervise the meal service to ensure the resident received the right diet. During an interview on [DATE] at 12:00 PM, the facility's Educator, Registered Nurse (RN) #2, confirmed all staff are trained extensively on the Food Service Duties: (Quick Reference). RN #2 stated all four (4) staff, (CNA #1, #2, #3 and RN #1), involved in the choking incident of Resident #1 on [DATE], had knowledge of the POL, which included Resident #1's diet. RN #2 stated the POL is updated daily and given to the nurses and dietary staff each day. RN #2 stated the four (4) staff involved had not followed the policies and procedures for serving residents food trays in the dining room, to ensure the resident received the right diet on [DATE]. RN #2 stated all staff were trained on Food Service Duties two (2) weeks prior to the incident on [DATE], with Resident #1. RN #2 stated the failure to follow the correct process resulted in Resident #1's choking episode and death. On [DATE] at 1:15 PM, an attempt was made to contact CNA #3 by phone without success. Review of a documented statement by CNA #3, dated [DATE] at 4:23 PM, revealed she observed Resident #2 eating food from a meal tray with Resident #1's name on the ticket. The statement revealed CNA #3 checked the meal tray, served to Resident #1, which contained dressing, roll and turkey. CNA #3's statement documented, give me the ticket. On [DATE] at 1:20 PM, an attempt was made by phone to contact CNA #1 without success. Review of a written statement by CNA #1, dated [DATE] at 2:07 PM, revealed Resident #2 ate Resident #1's noon meal on [DATE], and she had given Resident #1 the meal tray, which belonged to Resident #2. CNA #1's statement documented, RN #1 opened the lid of Resident #2's tray, and stated it was the same food. RN #1 instructed CNA #1 to give the meal tray to Resident #1. CNA #1's statement documented, I did what I was told and put the tickets with the tray. During an interview via phone, on [DATE] at 2:50 PM, RN #1 stated she did check the POL on [DATE]. She stated she did not pass out trays or hand trays to the CNAs. RN #1 stated, when made aware Resident #2 had eaten Resident #1's meal, she instructed CNA #1 to give Resident #1 another tray that was like the same diet as ordered for her. RN #1 did not follow up to ensure Resident #1 was served the correct diet. Review of the facility's individual training records and documented in-services revealed, all three (3) CNAs and RN #1 were in-serviced on New Employee Orientation, Meal and Hydration, Serving Meals in the Dining Room and Armband Checks, prior to the choking incident of Resident #1. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan/Corrective Actions, prior to the State Agency (SA) entrance on [DATE]. In response to the Immediate Jeopardy (IJ) that was cited at 3:30 PM on [DATE], the facility submitted a brief summary of the event, including an IJ Removal Plan and Corrective Actions, taken by the facility, to remove the Immediate Jeopardy (IJ): 1. Description Of Incident: Resident #1 was a [AGE] year old white female, admitted to the facility, on (MONTH) 24, 2019. Resident #1 had an admitting [DIAGNOSES REDACTED]. Resident #1 was admitted on a Regular Diet with No Corn, due to allergies [REDACTED].#1's diet was changed, by the physician, from a Regular Diet to a Mechanical Soft with Chopped Meat Diet, due to having a choking episode while eating peaches. On (MONTH) 24, 2019 at 12:15 PM, Resident #1 choked, while eating lunch in the dining room, due to receiving a Regular Diet, instead of a Mechanical Soft with Chopped Meat Diet, as ordered by the physician, and the care plan. Resident #1 passed away, on (MONTH) 27, 2019 at 9:15 AM, at the local hospital, due to [MEDICAL CONDITION]/[MEDICAL CONDITION], per local hospital records. 2. The facility's Hospital Director and Nursing Home Administrator were notified of the incident on (MONTH) 24, 2019 at 12:30 PM, by the facility's Dietary Manager. The Hospital Director gave directives to refer the incident to Investigative Services and the Quality Assurance Department. Investigative Services arrived at the facility and began an investigation of the incident on (MONTH) 24, 2019 at 12:55 PM. 3. Measures Implemented: The Quality Assurance (QA) Committee held an Emergency QA Meeting on (MONTH) 24, 2019 at 4:00 PM, with the following staff: Nursing Home Administrator, Nurse Manager, Medical Nurse Practitioner (Representing the Medical Director), Minimum Data Set (MDS) Coordinator, Contract Rehab Director, Nurse Supervisor, QA Nurse, and Investigator. The QA Committee reviewed the Abuse, Neglect and Exploitation Policy, discussed Accidents and Hazards; the QA Committee did not recommend any changes at this time. The QA Committee also reviewed the Food Service Duties Quick Reference and Resident #1's Care Plan. The QA Committee found that RN #1 and CNAs #1, #2 and #3 failed to follow the Food Service Duties Quick Reference, which resulted in Resident #1 receiving a Regular Diet, instead of a Mechanical Soft with Chopped Meat Diet, that was ordered by the physician, and noted on the care plan. The QA Committee recommended to immediately begin training all staff on following the Food Service Duties Quick Reference and following residents diets as care planned, to prevent accidents and hazards. The QA Committee recommended all staff on duty be trained before the next meal was served. The QA Committee also recommended that RN #1 and CNAs #1, #2, and #3 be placed on Administrative Leave, for serving Resident #1 the wrong diet, and not following policy and procedure. The QA Committee identified 39 of 101 residents, who were on mechanically altered diets, had the potential to be affected, by receiving an incorrect diet. On (MONTH) 24, 2019 at 5:00 PM, the Quality Assurance Nurse performed chart audits of the 39 residents, who had the potential to be affected, and found that no changes were needed. 4. Training/In-services: On (MONTH) 24, 2019 at 4:30 PM, the Nurse Supervisor began in-services on the Food Service Duties Quick Reference procedures for passing out meal trays with all staff. All staff working were trained prior to the next meal being served. The Nurse Supervisor began training for the oncoming night shift employees at 6:30 PM. On (MONTH) 25, 2019 at 6:30 AM, all oncoming staff were trained by the Nurse Supervisor before starting the shift. On (MONTH) 25, 2019 at 6:30 PM, all oncoming staff were trained by the Nurse Supervisor before starting the shift. All In-services were completed by (MONTH) 25, 2019 at 7:00 PM. Any staff that did not receive this training will be trained immediately upon returning to work. The following In-services covered: Accidents and Hazards and Supervision - All staff were trained on the Nurse checking the Physician order [REDACTED]. If supervision is not carried out it could result in a hazard and/or accident. Abuse/Neglect - All staff were trained on how to check the diet to ensure the correct diet consistency is on each meal tray for that particular resident per the Physicians Order List (POL). Diet - All staff were trained on the Nurse checking the Physicians Order List (POL) with the tray ticket for correct diet consistency, and whoever delivers the tray to the resident, must remove the lid from the tray to check the consistency of the food on the tray to the meal ticket. Care Plan - All staff were trained on each individual resident's diet consistency that is listed on the Physicians Order List (POL), which reflects the resident's Plan of Care. 5. All staff, including new hires, will receive training on food service prior to being able to work. 6. Disciplinary Actions: On (MONTH) 24, 2019, after the investigation was initiated, it was determined there was enough evidence to place CNAs #1, #2, #3 and RN #1 on administrative leave pending completion of the investigation. RN #1 resigned from employment on (MONTH) 25, 2019. CNA #1 was terminated from employment effective (MONTH) 31, 2019. CNA #2 was terminated from employment effective (MONTH) 30, 2019. CNA #3 was terminated from employment effective (MONTH) 30, 2019. 7. Notification of State Agencies: On (MONTH) 24, 2019 at 4:52 PM, the facility's Investigator notified the Mississippi State Department of Health (MSDH) by telephone. On (MONTH) 25, 2019 at 9:20 AM, the facility's Investigator notified The Mississippi Attorney General's Office in writing of the incident. 8. Removal of Immediate Jeopardy: All activities to remove the Immediate Jeopardy were accomplished on (MONTH) 25, 2019, and the facility alleges that the removal of the Immediate Jeopardy was effective as of (MONTH) 26, 2019. The State Agency (SA) validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observation, interview, and facility record review. 1. The SA validated through record review, staff interview, and video tape review of the incident, on [DATE], of Resident #1 choking in the dining room during the noon meal. The SA surveyor watched the video along with the facility Administrator. The SA validated Resident #1 had an order for [REDACTED].#1 was transferred to the hospital after a choking episode from the incorrect diet. Resident #1 expired on [DATE], related to the incident. 2. The SA validated the facility began an investigation of the choking incident on [DATE], after notification to the Administrator. 3. The SA validated the Quality Assurance (QA) signature sheets and documentation of the QA meeting, that was held on [DATE]. Interviews with the facility Administrator and QA Nurse/RN #4, validated the QA meeting of [DATE]. Interviews with the Director of Nursing (DON), the Minimum Data Set (MDS) Care Plan Coordinator/RN#5, and the QA Nurse/RN #4 validated that the orders and care plans of the 39 residents who had mechanically altered diets, were audited with no changes. The QA meeting included recommendations for training of staff for following resident's diets, as care planned, to prevent accidents and hazards. The SA interviewed the QA Nurse on [DATE], and validated the signature sheets and the topics discussed in the QA meeting. The QA Nurse confirmed some of the topics discussed in the QA meeting were Abuse and Neglect; Care Plans, Residents Diets and Service of Diets, Safety of Residents, and Prevention of Accidents. The QA Nurse stated the QA members made no further recommendations and determined there were four (4) staff members responsible for the noon meal of Resident #1, and on [DATE], they made the choice not to follow the established policies and procedures. The QA Nurse stated these four (4) staff neglected to follow the established policies and procedures and their choice caused Resident #1 to choke. 4. The SA reviewed the signature sheets for the training, which began on [DATE] and ended on [DATE]. The SA validated the in-services contained training on Abuse and Neglect, Safety, Residents Mechanically Altered Diets, Meal Service and Safety, Checking the Physician order [REDACTED]. Interviews and record reviews validated all staff had been in-serviced on their duty to monitor the dining room, provide the ordered diet, supervision of residents, abuse/neglect and care plans. During the survey, licensed nurses were observed in the dining room monitoring the meals of the residents, per policy and protocol. The facility provided documentation of training topics given to all staff on [DATE] and [DATE]. Copies of the training and the signature sheets were provided to the SA for validation. Interviews with licensed nursing staff, Food Service staff, Administrative staff, and Certified Nursing Assistant (CNA) staff, validated all staff working in the facility had been in-serviced on their duty to serve, check, cue, supervise, and monitor the residents for all meals, and knew the facility's policies and procedures for abuse and neglect. 5. The SA validated no staff worked prior to training of the Food Service Protocol and in-services. 6. The SA validated CNA #1, #2, #3 and RN #1 were suspended on [DATE], and are no longer employed by the facility. 7. The SA validated all appropriate State agencies were notified of the choking incident for Resident #1. 8. The SA accepted the facility's Removal Plan and determined all corrective actions were completed on [DATE], and the IJ was removed on [DATE], prior to the SA entrance on [DATE].

Based on observation, interview, record review and policy review, the facility failed to serve food to residents in accordance with the physician's order, for one (1) of four (4) residents, of 39 residents, with orders for Mechanically Altered Diets, Resident #1. An Immediate Jeopardy (IJ) existed on [DATE], when Resident #1 was served a Regular Diet with a piece of whole sliced turkey, instead of a Mechanical Soft Diet with Chopped Meats. Resident #1 choked on the whole sliced turkey, suffered cardiopulmonary arrest, was transferred to the hospital and placed on a ventilator. Resident #1 expired on [DATE], related to the choking incident, when she received the wrong diet. The facility's failure to serve Resident #1's food in accordance with the physician's order, resulted in the choking and subsequent death of Resident #1. This failure also placed other residents, with a mechanically altered diet, in a situation that was likely to cause serious harm, injury, impairment, or death. Based on the facility's IJ Removal Plan and corrective actions, completed on [DATE], prior to the State Agency (SA) entrance on [DATE], the SA determined the IJ was Past Non-Compliance (PNC) and the IJ removed as of [DATE]. The SA notified the Administrator of the PNC IJ and SQC on [DATE] at 3:30 PM. Findings Include: Review of the facility's Special Food Services Protocol: Therapeutic Programming Snack & Special Event (Protocol ,[DATE]) policy, dated (MONTH) 2013, revealed the Physicians Orders List (POL) will be utilized to verify food consistency. The POL will be updated daily Monday - Friday by the Minimum Data Set (MDS) staff and a copy of the POL will be provided to the Nurse's Station on both halls. Staff assisting with meal service will be familiar with special diet considerations which are part of the Physicians Orders List. This includes identification of food consistency required by any listed diet and any special considerations including allergies [REDACTED]. If any discrepancy is noted between the Food Service Meal Ticket and the POL, a nurse will consult the Physician's Order in the Medical Record for clarifications. If the POL is not present in the dining room, or at the location where food or beverage is served, then NO food or beverage may be offered until the list is available and checked for reference. Review of the facility's Food Service Duties (Quick Reference)policy and procedure, dated (MONTH) 2013, revealed: Dining Room (Anytime Food Is Served) 2. NURSE ONLY checks Physician Order List (POL) with Meal Service Ticket. Check ticket ONLY for basic diet and food/beverages consistency with the POL, if discrepancy noted, notify the Unit Nurse to check the Physician's Order for verification of correct diet. 3. CNAs or staff assigned to Dining Room Duty that day, will serve meal trays after the nurse has checked the ticket. When the tray is taken to the resident, meal ticket is checked with the resident's identification arm band. If the resident has no arm band, ask the nurse in the dining room area to verify the resident's identity and consistency on the POL, and serve food. Check basic diet and food/beverage consistency on tray ticket with the food on the tray. If there is a discrepancy, notify the kitchen staff the food is not correct. Review of the facility's Mechanical Soft/Chopped Entree definition, from a Modified Diets In-service Form, undated, revealed the definition: A near regular diet with the exception all meats must be chopped into small pea sized or less pieces. Review of Resident #1's (MONTH) 2019 Physician Orders revealed an order, initiated on [DATE], for a Mechanical Soft With Chopped Meats. Review of an evaluation from Speech Therapy, dated [DATE], revealed Resident #1 had a [DIAGNOSES REDACTED]. Record Review of the daily Physician Orders List (POL) dated [DATE] revealed a diet order for Resident #1, dated [DATE], Meals QD (every day) Mechanical Soft with Chopped Meats. Record review of Resident #1's food tray ticket, dated [DATE], revealed resident was to be served one-half (,[DATE]) cup Chopped Turkey with Gravy. Review of an Investigative Summary Report, dated [DATE], for Resident #1, revealed, Resident #1 became choked while eating a Regular Diet instead of the ordered diet of Mechanical Soft with Chopped Meats, served by Certified Nursing Assistant (CNA) #1. Staff initiated abdominal thrusts and Cardio-pulmonary Resuscitation (CPR). Resident #1 was transferred via ambulance to the emergency room (ER) for further medical treatment. Resident #1 was placed on a ventilator, then expired on [DATE], as a result of the choking incident. The investigation revealed, nursing staff violated facility Protocol ,[DATE], by failure to verify and ensure the correct diet was served to Resident #1. Review of a Medical Nutrition Therapy Long Term Care (LTC) Assessment, dated [DATE], revealed Resident #1 required a Mechanical Soft Diet with Chopped Meats. During an interview, on [DATE] at 11:15 AM, the facility's Investigator, Licensed Practical Nurse (LPN) #1, confirmed through his investigation, Resident #1 choked and ultimately died because she was served the wrong diet by facility staff on [DATE]. During an interview, on [DATE] at 11:20 AM, Speech Therapist (ST) #1 revealed, Speech Therapy recommended the Mechanical Soft Diet with Chopped Meats for Resident #1 related to rate issues and risk of choking. During an interview, on [DATE] at 12:10 PM, the Dietary Manager (DM) stated the dietary department receives a new up-dated POL daily, prepares the food, and fills the food trays in accordance with the POL. The Nurse assigned to the dining room gets an updated POL and it is her responsibility to check the food tickets against the daily POL. Once the nurse checks the POL against the food tray tickets, then the CNAs take the tray, and distributes to the residents after they check the resident's arm bands for identity. During an interview, on [DATE] at 12:00 PM, and again on [DATE] at 12:15 PM, Educator/Staff Development Registered Nurse (RN) #2 confirmed all nursing staff and Certified Nursing Assistants (CNA's) are trained on a regular basis about serving correct diets. RN #2 confirmed all four (4) staff, (CNA #1, #2, #3 and RN #1), involved in the incident with Resident #1 on [DATE], at the noon meal, were well trained. She stated they knew what the processes were, and made the choice not to follow the facility's policies and procedures for dietary services to ensure Resident #1 received the right diet. During an interview, on [DATE] at 3:35 PM, CNA #4 stated she was in the dining room on [DATE] when Resident #1 had the choking incident. CNA #4 confirmed staff had been trained on diets and tray service approximately one (1) to two (2) weeks prior to this incident. CNA #4 confirmed they were never to leave a tray on the table unattended. Interview on [DATE] at 3:00 PM, with the Registered Dietician (RD), revealed he teaches and in-services all staff in the facility on dietary services and the policies and procedures of food services Quick References. He stated he trains the staff on cueing the residents during meals and assisting and monitoring residents during meals. The RD stated he trains staff about therapeutic diets and he teaches the staff how to set-up food trays for serving, and to make sure the tray ticket matches what is on the tray. The RD stated all staff had been aware Resident #1 required a Mechanical Soft Diet with Chopped Meats. On [DATE] at 1:15 PM, an attempt was made to contact CNA #3 by phone without success. Review of a documented statement by CNA #3, dated [DATE] at 4:23 PM, revealed she observed Resident #2 eating food from a meal tray with Resident #1's name on the ticket. There was no meat on the tray Resident #2 was eating. CNA #3 documented she checked the meal tray, served to Resident #1 by CNA #1, which had the same items with the addition of turkey. CNA #3 documented, give me the ticket. On [DATE] at 1:20 PM, an attempt was made by phone to contact CNA #1 without success. Review of a written statement by CNA #1, dated [DATE] at 2:07 PM, revealed Resident #2 ate Resident #1's noon meal tray on [DATE], and she gave Resident #1 the meal tray, which belonged to Resident #2. The written statement documented, RN #1 opened the lid of Resident #2's tray, stated it was the same food, and instructed CNA #1 to serve the meal tray to Resident #1. CNA #1 documented, I did what I was told and put the tickets with the tray. In an interview by phone, on [DATE] at 2:50 PM, RN #1 confirmed she checked the food tray tickets against the Physician's Order List (POL). RN #1 stated she learned how to check the food tray tickets against the POL by other nurses passing the information to her in reports. She stated she had never been trained on the procedure of checking food trays against the POL and/or serving meal trays. RN #1 stated she did pass out trays and did not hand trays to CNAs. RN #1 stated she never told CNA #1 to serve Resident #1 the food tray of Resident #2; she told CNA #1 to give Resident #1 another tray that was the same diet, which was Mechanical Soft with Chopped Meats. RN #1 stated she resigned her position at the facility. Review of the facility's individual training records and documented in-services revealed, CNA #1 was trained on [DATE], on the POL Protocol. CNA #1 was trained on Special Diets, Serving Meals, and the POL on [DATE]. Review of the facility's individual training records and in-services for CNA #2, revealed she was trained on the POL on [DATE]. CNA #2 was trained on Special Diets and the POL on [DATE]. On [DATE], and [DATE], CNA #2 was trained on the POL Protocol, as well as checking the armbands to make sure the right resident is getting the right meal on [DATE]. Review of the individual facility's training records and in-services for CNA #3, revealed she was trained on the POL Protocol on [DATE], and [DATE]. On [DATE], CNA #3 was trained on checking the armbands to ensure the right resident is getting the right meal. CNA #3 was trained on [DATE], on the POL and Serving Meals. Review of the facility's training record and in-services revealed, RN #1 was trained on the POL Protocol on [DATE]. RN #1 was trained on Special Diets/Serving on [DATE]. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan/Corrective Actions, prior to the State Agency (SA) entrance on [DATE]. In response to the Immediate Jeopardy (IJ) that was cited at 3:30 PM on [DATE], the facility submitted a brief summary of the event, including an IJ Removal Plan and Corrective Actions, taken by the facility, to remove the Immediate Jeopardy (IJ): 1. Description Of Incident: Resident #1 was a [AGE] year old white female, admitted to the facility, on (MONTH) 24, 2019. Resident #1 had an admitting [DIAGNOSES REDACTED]. Resident #1 was admitted on a Regular Diet with No Corn, due to allergies [REDACTED].#1's diet was changed, by the physician, from a Regular Diet to a Mechanical Soft with Chopped Meat Diet, due to having a choking episode while eating peaches. On (MONTH) 24, 2019 at 12:15 PM, Resident #1 choked, while eating lunch in the dining room, due to receiving a Regular Diet, instead of a Mechanical Soft with Chopped Meat Diet, as ordered by the physician, and the care plan. Resident #1 passed away, on (MONTH) 27, 2019 at 9:15 AM, at the local hospital, due to [MEDICAL CONDITION]/[MEDICAL CONDITION], per local hospital records. 2. The facility's Hospital Director and Nursing Home Administrator were notified of the incident on (MONTH) 24, 2019 at 12:30 PM, by the facility's Dietary Manager. The Hospital Director gave directives to refer the incident to Investigative Services and the Quality Assurance Department. Investigative Services arrived at the facility and began an investigation of the incident on (MONTH) 24, 2019 at 12:55 PM. 3. Measures Implemented: The Quality Assurance (QA) Committee held an Emergency QA Meeting on (MONTH) 24, 2019 at 4:00 PM, with the following staff: Nursing Home Administrator, Nurse Manager, Medical Nurse Practitioner (Representing the Medical Director), Minimum Data Set (MDS) Coordinator, Contract Rehab Director, Nurse Supervisor, QA Nurse, and Investigator. The QA Committee reviewed the Abuse, Neglect and Exploitation Policy, discussed Accidents and Hazards; the QA Committee did not recommend any changes at this time. The QA Committee also reviewed the Food Service Duties Quick Reference and Resident #1's Care Plan. The QA Committee found that RN #1 and CNAs #1, #2 and #3 failed to follow the Food Service Duties Quick Reference, which resulted in Resident #1 receiving a Regular Diet, instead of a Mechanical Soft with Chopped Meat Diet, that was ordered by the physician, and noted on the care plan. The QA Committee recommended to immediately begin training all staff on following the Food Service Duties Quick Reference and following residents diets as care planned, to prevent accidents and hazards. The QA Committee recommended all staff on duty be trained before the next meal was served. The QA Committee also recommended that RN #1 and CNAs #1, #2, and #3 be placed on Administrative Leave, for serving Resident #1 the wrong diet, and not following policy and procedure. The QA Committee identified 39 of 101 residents, who were on mechanically altered diets, had the potential to be affected, by receiving an incorrect diet. On (MONTH) 24, 2019 at 5:00 PM, the Quality Assurance Nurse performed chart audits of the 39 residents, who had the potential to be affected, and found that no changes were needed. 4. Training/In-services: On (MONTH) 24, 2019 at 4:30 PM, the Nurse Supervisor began in-services on the Food Service Duties Quick Reference procedures for passing out meal trays with all staff. All staff working were trained prior to the next meal being served. The Nurse Supervisor began training for the oncoming night shift employees at 6:30 PM. On (MONTH) 25, 2019 at 6:30 AM, all oncoming staff were trained by the Nurse Supervisor before starting the shift. On (MONTH) 25, 2019 at 6:30 PM, all oncoming staff were trained by the Nurse Supervisor before starting the shift. All In-services were completed by (MONTH) 25, 2019 at 7:00 PM. Any staff that did not receive this training will be trained immediately upon returning to work. The following In-services covered: Accidents and Hazards and Supervision - All staff were trained on the Nurse checking the Physician Order List (POL) against the tray ticket, supervision of the resident getting the correct meal tray. If supervision is not carried out it could result in a hazard and/or accident. Abuse/Neglect - All staff were trained on how to check the diet to ensure the correct diet consistency is on each meal tray for that particular resident per the Physicians Order List (POL). Diet - All staff were trained on the Nurse checking the Physicians Order List (POL) with the tray ticket for correct diet consistency, and whoever delivers the tray to the resident, must remove the lid from the tray to check the consistency of the food on the tray to the meal ticket. Care Plan - All staff were trained on each individual resident's diet consistency that is listed on the Physicians Order List (POL), which reflects the resident's Plan of Care. 5. All staff, including new hires, will receive training on food service prior to being able to work. 6. Disciplinary Actions: On (MONTH) 24, 2019, after the investigation was initiated, it was determined there was enough evidence to place CNAs #1, #2, #3 and RN #1 on administrative leave pending completion of the investigation. RN #1 resigned from employment on (MONTH) 25, 2019. CNA #1 was terminated from employment effective (MONTH) 31, 2019. CNA #2 was terminated from employment effective (MONTH) 30, 2019. CNA #3 was terminated from employment effective (MONTH) 30, 2019. 7. Notification of State Agencies: On (MONTH) 24, 2019 at 4:52 PM, the facility's Investigator notified the Mississippi State Department of Health (MSDH) by telephone. On (MONTH) 25, 2019 at 9:20 AM, the facility's Investigator notified The Mississippi Attorney General's Office in writing of the incident. 8. Removal of Immediate Jeopardy: All activities to remove the Immediate Jeopardy were accomplished on (MONTH) 25, 2019, and the facility alleges that the removal of the Immediate Jeopardy was effective as of (MONTH) 26, 2019. The State Agency (SA) validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observation, interview, and facility record review. 1. The SA validated through record review, staff interview, and video tape review of the incident, on [DATE], of Resident #1 choking in the dining room during the noon meal. The SA surveyor watched the video along with the facility Administrator. The SA validated Resident #1 had an order for [REDACTED].#1 was transferred to the hospital after a choking episode from the incorrect diet. Resident #1 expired on [DATE], related to the incident. 2. The SA validated the facility began an investigation of the choking incident on [DATE], after notification to the Administrator. 3. The SA validated the Quality Assurance (QA) signature sheets and documentation of the QA meeting, that was held on [DATE]. Interviews with the facility Administrator and QA Nurse/RN #4, validated the QA meeting of [DATE]. Interviews with the Director of Nursing (DON), the Minimum Data Set (MDS) Care Plan Coordinator/RN#5, and the QA Nurse/RN #4 validated that the orders and care plans of the 39 residents who had mechanically altered diets, were audited with no changes. The QA meeting included recommendations for training of staff for following resident's diets, as care planned, to prevent accidents and hazards. The SA interviewed the QA Nurse on [DATE], and validated the signature sheets and the topics discussed in the QA meeting. The QA Nurse confirmed some of the topics discussed in the QA meeting were Abuse and Neglect; Care Plans, Residents Diets and Service of Diets, Safety of Residents, and Prevention of Accidents. The QA Nurse stated the QA members made no further recommendations and determined there were four (4) staff members responsible for the noon meal of Resident #1, and on [DATE], they made the choice not to follow the established policies and procedures. The QA Nurse stated these four (4) staff neglected to follow the established policies and procedures and their choice caused Resident #1 to choke. 4. The SA reviewed the signature sheets for the training, which began on [DATE] and ended on [DATE]. The SA validated the in-services contained training on Abuse and Neglect, Safety, Residents Mechanically Altered Diets, Meal Service and Safety, Checking the Physician Order List (POL), Care Plans, and Accidents/Hazards. Interviews and record reviews validated all staff had been in-serviced on their duty to monitor the dining room, provide the ordered diet, supervision of residents, abuse/neglect and care plans. During the survey, licensed nurses were observed in the dining room monitoring the meals of the residents, per policy and protocol. The facility provided documentation of training topics given to all staff on [DATE] and [DATE]. Copies of the training and the signature sheets were provided to the SA for validation. Interviews with licensed nursing staff, Food Service staff, Administrative staff, and Certified Nursing Assistant (CNA) staff, validated all staff working in the facility had been in-serviced on their duty to serve, check, cue, supervise, and monitor the residents for all meals, and knew the facility's policies and procedures for abuse and neglect. 5. The SA validated no staff worked prior to training of the Food Service Protocol and in-services. 6. The SA validated CNA #1, #2, #3 and RN #1 were suspended on [DATE], and are no longer employed by the facility. 7. The SA validated all appropriate State agencies were notified of the choking incident for Resident #1. 8. The SA accepted the facility's Removal Plan and determined all corrective actions were completed on [DATE], and the IJ was removed on [DATE], prior to the SA entrance on [DATE].

Based on observation, staff interview, and facility policy review, the facility failed to properly store drugs and biologicals as evidenced by expired medication in the medication room on the Magnolia Hall, for one (1) of two (2) medication rooms observed. Findings include: Review of the facility's policy titled, Floor Stock Medication, revised (MONTH) (YEAR), revealed: Procedure: A. (2) It is the responsibility of the unit nurse to rotate floor stock and return any outdated floor stock medication. (3) It is the responsibility of the unit nurse to maintain proper storage of floor stock medications. G. Medication Room Inspection for Inpatient Services: The Pharmacy will perform random unit medication room inspections to ensure the following, but is not limited to: C. Expired medications have been returned to Pharmacy. On 4/17/19 at 8:40 AM, an observation of the Medication Room on the Magnolia Hall revealed three (3) bottles of Liquid Tylenol Pain and Fever medication with an expiration date of 8/18. An interview at that time with Licensed Practical Nurse (LPN) #1 revealed she stated she did not know the facility's policy for checking for expired medications. LPN #1 confirmed she had no liquid Tylenol available for resident use, that was in date. LPN #1 stated if she needed liquid Tylenol she would have to order it. On 4/17/19 at 8:53 AM, an interview with LPN #2 revealed the Medication Nurse was responsible for checking for expired medications. On 4/17/19 at 8:54 AM, an interview with the Nursing Supervisor revealed the Medication Nurse was responsible for checking for expired medications and notifying the Registered Nurse (RN) Supervisor if any are expired, for removal and disposal.

Based on observation, staff interview, record review, and facility policy review, the facility failed to develop and/or implement the care plan for monitoring and releasing Resident #14's Posey hand mitts, checking Resident #33's Percutaneous Endoscopic Gastrostomy (PEG) tube for placement and patency prior to medication administration, provide Resident #45's [MEDICAL CONDITION] care as needed, and to ensure Resident #66's hand mitts were removed to provide skin inspection and hand washing/cleaning. These concerns were identified for four (4) of 24 resident care plans reviewed. Findings include: Review of the facility's policy titled, Interdisciplinary Care Plan, with a revision date of (MONTH) (YEAR), revealed it is the policy of the facility to develop a written individualized care plan that meets the needs and choices of each resident as well as addresses the strength, weaknesses, and goals identified by the resident's assessment, reassessment, and results of diagnostic testing. Appropriate consideration and monitoring of factors that commonly contributes to the health and well-being of residents over the course of treatment, including but not limited to: Restraint use, Medication Regimens, and Nutrition and hydration requirements. The interdisciplinary care plan will have treatment objectives with measurable outcomes within a specific timetable, identify the person responsible for implementing the approaches as well as a plan for re-evaluation. Receive updates as care needs change. The interdisciplinary care plan will be reviewed and revised to reflect changes in the resident's condition when the assessment is completed every quarter, annually, on significant change, and anytime there is an acute change in the condition of the resident. Resident #14 Review of Resident #14's Care Plan regarding the use of restraints, with an onset date of 11/27/17, included approaches to remove mittens every two hours for 10 minutes per restraint protocol, check circulation, and provide ROM (Range of Motion), every thirty minute checks for safety, remove for meals, and checks should be documented. Observation and interviews, on 02/27/18 from 8:27 AM through 11:00 AM, revealed Resident #14 was in her room seated in a geri chair with a hand mitt on each hand. At approximately 8:47 AM, Certified Nursing Assistant (CNA) #3 and CNA #4 entered the room to assess the resident for incontinent care. Both CNAs stated the resident wore the hand mitts at all times. CNA #3 stated she had never taken the mitts off when caring for the resident, but would check them to make sure they weren't causing any irritation of her skin. CNA #3 stated she would check them when she checked to see if the resident needed incontinent care, about every two hours. At approximately 10:00 AM, CNA #5 entered the resident's room with her pudding snack. CNA #5 stated she frequently fed the resident her snacks and lunch, and did not release the hand mitts for snacks or meals. CNA #5 stated she normally released the mitts once in a shift for about 10 minutes. At 11:00 AM, RN #6 entered the resident's room to administer medication. RN #6 mixed the resident's medication with applesauce, and administered it to the resident by spoon. RN #6 checked the hand mitts at each wrist. RN #6 stated she was checking the resident for circulation. RN #6 stated it was the nurse's responsibility to release the hand mitts every two hours for 10 minutes. RN #6 stated she had been on the hall since 8:00 AM this morning, and had not released the hand mitts, but was about to. RN #6 stated she was running behind, and had failed to release the hand mitts within two hours, and was unsure when the last time they had been released. An observation, on 02/21/18 at 10:46 AM, revealed Resident #14 was sitting in a geri chair. Resident #14 had a soft enclosed hand mitten on each hand. A review of Resident #14's medical record revealed a physician's orders [REDACTED]. A review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ADR) of 12/06/17, revealed Resident #14 was checked/assessed for a restraint worn seven days a week. An interview, on 02/23/18 at 8:40 AM, with Certified Nursing Assistant (CNA) #1 and CNA #2, revealed Resident #14 would bite her own fingers, and pick her teeth and face, and wore the posey mitts for these behaviors. Both CNAs stated the mitts were removed for ten minutes every two hours. CNA #1 stated they normally would take the hand mitts off for meals, and when they changed the resident's brief. An interview, on 02/23/18 at 9:00 AM, with Registered Nurse (RN) #7, revealed Resident #14 had a behavior of biting her fingers. RN #7 stated the resident wore the posey mitts on her hands to prevent her from biting her fingers, and this intervention has been effective. RN #7 stated nursing staff monitor the resident's hand mitt restraints on the residents Activities of Daily Living (ADL) form, and check the resident every 30 minutes for safety, and release the hand restraints every two hours. An interview, on 02/23/18 at 9:28 AM, revealed the Nurse Practitioner (NP) stated the resident's need for the posey hand mitts was reviewed monthly in the care plan interdisciplinary meetings. The NP stated he would expect the nursing staff to do safety checks every 30 minutes of the resident to ensure no issues with circulation. An observation, on 02/23/18 at 2:14 PM, revealed Resident #14 in her room seated in her geri chair with the hand mitts on both hands. A review of Resident #14's ADL Records revealed nursing staff were initialing every 12 hour shift, 7 AM to 7 PM, and 7 PM to 7 AM, that every thirty minute safety checks, and every two hour releases of the hand mitts were being done. The ADL Record did not document each 30 minute check, or two hour release individually, just every 12 hour shift. A review of the Nurse's Notes, dated 11/27/17, when the hand mitts were ordered, through 02/27/18, revealed nurses had documented regarding the resident being on every thirty minute safety checks with mitts in place on each 12 hour shift, but there were only four entries during that time period that indicated the resident had mitts released. An interview, on 02/27/18 at 11:00 AM, with RN #5/Minimum Data Set (MDS) Nurse, revealed he was responsible for writing and updating the care plan. The MDS Coordinator stated staff should follow the interventions on the care plan to check the resident every thirty minutes, and release the hand mitts every two hours, and document. RN #5 stated if the interventions were not done, the care plan was not followed. Resident #33 Review of Resident #33's Care Plan, dated 12/28/17, for Nutritional Deficit Related To Poor Oral Intake, and PEG tube for supplementation, revealed no approaches to address checking the PEG tube for placement and patency prior to medication administration. An observation and interview, on 02/23/18 at 12:19 PM, revealed RN #4 administered Resident #33's [MEDICATION NAME] via her PEG tube without checking for placement and patency. RN #4 stated he did not check Resident #33's PEG tube placement and patency prior to the administration of the [MEDICATION NAME]. On 03/01/18 at 10:30 AM, an interview and record review, with RN #4, revealed he had reviewed the Care Plan, and stated he didn't know about the care plan, and did not follow it. Resident #45 A review of Resident #45's Care Plan, dated 1/10/18, revealed the care plan included approaches to be performed by nurses which included changing the the [MEDICAL CONDITION] collar every two days and as needed for wetness, and to suction the [MEDICAL CONDITION] with sterile water every four hours and as needed for secretions. The care plan also included an intervention for nursing assistants to monitor and report to the charge nurse any increased secretions. An observation, on 02/21/18 at 11:20 AM, revealed Resident #45 was in his room, lying in bed with a [MEDICATION NAME] mask over the resident's stoma. There was audible slight gurgling sounds at the [MEDICAL CONDITION] site with visible drainage on the resident's neck and clothing. At 11:25 AM, the resident coughed up a large amount of thick white mucus that collected in his [MEDICAL CONDITION] collar/mask, and down onto the top of his shirt. An observation, on 02/21/18 at 2:15 PM, revealed Resident #45 had thick white sputum accumulated in his [MEDICAL CONDITION] mask, and dripping onto his clothing. Resident #45 had on the same shirt as the previous observation at 11:20 AM. An observation, on 02/23/18 at 9:43 AM, revealed Resident #45 had coughed up thick mucous which had collected in his [MEDICAL CONDITION] mask. On 2/22/18 at 3:15 PM, an interview with the Minimal Data Set (MDS) Coordinator verified that all nursing staff are trained to follow the plan of care. If nursing staff did not monitor, and notify the charge nurse for secretions, or other [MEDICAL CONDITION] needs, the care plan was not followed. On 2/22/18 at 3:30 PM, the Director of Nursing (DON) said that training, explanations and verifications of understanding of the care plan purpose and usage are completed on each nursing staff member. When the DON reviewed the care plan, the DON agreed that the statement PRN means as needed, and the resident should receive [MEDICAL CONDITION] care as needed for wetness, gurgling, and visual secretions. The DON stated the staff has not done this as the care plan directs. Resident #66 Review of Resident #66's medical records, revealed a Care Plan related to the use of bilateral hand mittens, without an intervention for providing hand care. Further review of the care plan revealed a potential for skin break down, with an onset date of 01/14/18, that revealed an intervention to observe the resident's skin daily during care, and to report any irritation, redness or breakdown, as per the certified nurse aide. An observation of Resident #66's hands, and interview with Certified Nurse Aide (CNA) #1 and Licensed Practical Nurse (LPN) #2, on 02/22/18 at 10:01 AM, revealed the resident was wearing bilateral soft hand mittens which had dark brown/red colored stains to the palm side of her left hand mitten. When CNA #1 removed the resident's left mitten she and LPN #2, confirmed there was an offensive odor to the resident's contracted hand. An interview, on 03/01/18 at 9:30 AM, with the Director of Nursing (DON), confirmed the facility's staff are responsible for providing hand hygiene during AM care for resident's with hand mittens. The DON said Resident #66 should have had her hand mittens removed, and her hands washed to prevent them from being malodorous and unclean. An interview with the Staff Development Nurse, on 03/01/18 at 11:07 AM, revealed the staff are expected to provide hand hygiene to all dependent residents. The Staff Develop Nurse said the staff failed to remove the resident's hand mittens, and provide hand hygiene to Resident #66. Review of the resident's Face Sheet revealed Resident #66 was admitted by the facility, on 10/15/12, with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set, with an Assessment Reference Date of 01/16/18, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.

Based on observation, staff interview, record review, review of the facility's training resources, and facility policy review, the facility failed to ensure Resident #45 received [MEDICAL CONDITION] care as needed, and Resident #66 received oxygen (O2) therapy, for two (2) of four (4) residents reviewed for respiratory care. Findings include: Review of the facility's [MEDICAL CONDITION] Training Resources, dated (MONTH) (YEAR), revealed residents should be suctioned for [MEDICATION NAME] secretions and visible or audible gurgling sounds, and it is a sterile procedure. Hazards include infection and displacement or de-cannulation of the [MEDICAL CONDITION]. Each staff member interviewed said they are trained upon hire for [MEDICAL CONDITION] and stoma care. Review of the facility's policy titled, Routine Nursing Orders related to oxygen therapy, amended 07/17, revealed oxygen therapy for [MEDICAL CONDITIONS] exacerbation, SOB (Shortness of Breath), or dyspnea: Oxygen at 2-4 liters per minute via nasal cannula to keep oxygen above 92%. If the oxygen sats are below 92% inform the physician or Nurse Practitioner. If there are signs of respiratory distress such as cyanosis, respiratory rate greater than 30, oxygen saturation below 85%, or the resident is unconscious, send the resident to the emergency department. Resident #45 On 02/21/18 at 11:20 AM, an observation revealed Resident #45 was in his room lying in bed. Resident #45 had an [MEDICATION NAME] mask over the a [MEDICAL CONDITION] stoma. There were audible slight gurgling sounds at the [MEDICAL CONDITION] site with visible drainage on the resident's neck and clothing. At 11:25 AM, the resident coughed up a large amount of thick white mucus which collected in his [MEDICAL CONDITION] collar/mask, and down onto the top of his shirt, An observation, on 02/21/18 at 2:15 PM, revealed Resident #45 had thick white sputum accumulated in his [MEDICAL CONDITION] mask dripping onto his clothing. Resident #45 had on the same shirt as the previous observation at 11:20 AM. On 02/23/18 at 9:43 AM, Resident #45 was observed with thick mucous he had coughed up, and collected in his [MEDICAL CONDITION] mask. On 02/26/18 at 9:48 AM, an observation of Resident #45 revealed thick mucous accumulation around his [MEDICAL CONDITION] opening inside his oxygenation mask. Thick sputum was running down from the [MEDICAL CONDITION] opening, past the t-tube dressing, and down onto the resident's clothing protector. An interview and observation, on 02/28/18 10:15 AM, revealed Registered Nurse (RN) #1 assisted by Licensed Practical Nurse (LPN) #2, performed Resident #45's [MEDICAL CONDITION] care. RN #1 opened the [MEDICAL CONDITION] kit, applied the sterile gloves, and poured the hydrogen peroxide into the container. There was a bottle of sterile water on the surface barrier, and RN #1 handled the sealed lid on the sterile water with her sterile gloves, therefore contaminating the gloves at this point, and continued to complete the [MEDICAL CONDITION] care wearing the contaminated gloves. An interview at this time with RN #1 revealed she knew how to perform [MEDICAL CONDITION] care, and as an RN she should know how. RN #1 stated it was in her scope of practice. RN #1 acknowledged she had contaminated the sterile field by using the sterile gloves to try to open the bottle of sterile water, and then contaminated the resident's [MEDICAL CONDITION] care procedure. Resident #66 An observation, on 02/22/18 at 10:07 AM, revealed Resident #66 was lying in bed. Resident #66 was alert, and exhibiting restlessness as she made grunting noises. Resident #66 was rubbing her hands together which had bilateral hand mitts in place. She denied any pain or discomfort. The resident's oxygen tubing via nasal prongs was hanging over the left upper side rail with the oxygen concentrator running at 2 L (liters)/minute. Review of the Resident #66's physician's orders [REDACTED]. An observation and interview, with Licensed Practical Nurse (LPN) #2, on 02/22/18 at 10:12 AM, revealed LPN #2 obtained an O2 saturation level on the resident of 86% (percent). LPN #2 said the resident's oxygen saturation level was to be checked as needed per the physician's orders [REDACTED]. She placed the oxygen tubing via nasal prongs on the resident, and confirmed the resident needed it. Observation of Resident #66, on 02/22/18 at 11:12 AM, revealed she was lying in bed, calm without complaints, and with O2 in use via the nasal bi-prongs at 2 L/minute. Observation and interview with LPN #2, related to Resident #66's oxygen saturation level, on 02/22/18 at 12:50 PM, revealed the resident's oxygen saturation level was now at 96%, with the resident on O2 at 2 L/minute via nasal cannula. The resident is calm, with her eyes closed, and the rise and fall of her chest was observed without any difficulty. An interview, on 03/01/18 at 9:30 AM, with the Director of Nursing (DON), confirmed the nurses are responsible for checking the oxygen saturation level on residents when they have restlessness, shortness of breath (SOB), respiratory distress, and when they are not wearing oxygen. The DON said she would expect the nurses to use their nursing judgement as when to check the resident's oxygen saturation level. An interview, on 03/01/18 at 11:15 AM, with the Medical Director, revealed the nurses are responsible for recognizing respiratory distress in the residents, such as knowing when the resident is struggling to breathe, has skin discoloration, coolness to the skin. The Medical Director said she would expect the nurse to check the oxygen saturation level, and apply the oxygen as needed. Review of the resident's Face Sheet revealed the resident was admitted by the facility, on 10/15/12. Resident #66's [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set, with an Assessment Reference Date of 01/16/18, Section O, revealed the resident was prescribed oxygen therapy. Resident #66 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment.

Based on observation, staff interview, and facility policy review, the facility failed to ensure Resident #14's restraint was monitored every 30 minutes, and released every two (2) hours for one (1) of three (3) residents reviewed for restraints. Findings include: Review of the facility's policy titled, Restraints, with a revision date of (MONTH) 2012, revealed residents who were restrained would be monitored every 30 minutes. Employees assigned to the resident were to document on the resident's Monitoring Record. The restraint was to be removed for 10 minutes every two hours. The policy also stated restraints would be removed during meals. An observation, on 02/21/18 at 10:46 AM, revealed Resident #14 was sitting in a geri chair. Resident #14 was alert with looseness of association (a thought disorder in which a series of ideas are presented with loosely apparent or completely apparent logical connections). Resident #14 occasionally answered questions appropriately. Resident #14 was wearing soft enclosed hand mittens on each hand. Observation and interviews, on 02/27/18 from 8:27 AM through 11:00 AM, revealed Resident #14 was in her room seated in a geri chair with hand mitts on bilateral hands. At approximately 8:47 AM, CNA #3 and CNA #4 entered the room to assess the resident for her need for incontinent care. Both CNAs stated the resident wore the hand mitts at all times. CNA #3 stated she had never taken the mitts off when caring for the resident, but would check them to make sure they weren't causing any irritation of her skin. CNA #3 stated she would check them when she checked if the resident needed incontinent care, about every two hours. At approximately 10:00 AM, CNA #5 entered the resident's room with a snack of pudding. CNA #5 stated she frequently fed the resident her snacks and lunch, and did not release the hand mitts for snacks or meals. CNA #5 stated she normally released the mitts once in a shift for around 10 minutes. At 11:00 AM, RN #6 entered the resident's room to administer medication. RN #6 mixed the resident's medication with applesauce, and administered it to the resident by spoon. RN #6 checked the hand mitts at each wrist. RN #6 stated she was checking the resident for circulation. RN #6 stated it was the nurse's responsibility to release the hand mitts every two hours for 10 minutes. RN #6 stated she had been on the hall since 8:00 AM this morning, and had not released the hand mitts but was about to. RN #6 stated she was running behind, and had failed to release the hand mitts within two hours, and was unsure when the last time they had been released. A review of Resident #14's medical record revealed a physician's orders [REDACTED]. A review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ADR) of 12/06/17, revealed Resident #14 was checked/assessed for a restraint worn seven days a week. A review of Resident #14's Care Plan regarding the use of restraints, with an onset date of 11/27/17, included approaches to remove mittens every two hours for 10 minutes per restraint protocol, check circulation and provide ROM (Range of Motion), every thirty minute checks for safety, remove for meals, checks should be documented. An interview, on 02/23/18 at 8:40 AM, with Certified Nursing Assistant (CNA) #1 and CNA #2, revealed Resident #14 would bite her own fingers, and pick her teeth and face, and wore the posey mitts for these behaviors. Both CNAs stated the mitts were removed for ten minutes every two hours. CNA #1 stated they normally would take the hand mitts off for meals, and when they changed the resident's brief. An interview, on 02/23/18 at 9:00 AM, with Registered Nurse (RN) #7, revealed Resident #14 did not exhibit any aggressive behavior, but had a behavior of biting her fingers. RN #7 stated the resident wore the posey mitts on her hands to prevent her from biting her fingers, and this intervention has been effective. RN #7 stated nursing staff monitor the resident's hand mitt restraints on the residents Activities of Daily Living (ADL) form, and in the Nurse's Notes. RN #7 stated the staff was to check the resident every 30 minutes for safety, and release the hand restraints every two hours. An interview, on 02/23/18 at 9:28 AM, with the Nurse Practitioner (NP) revealed Resident #14 had an Anxiety Disorder and Atypical [MEDICAL CONDITION], and would get anxious, and bite her fingers until they would bleed. The NP stated the resident has the posey mitts to prevent her from biting her fingers. The NP stated the resident's need for the posey hand mitts was reviewed monthly in the care plan interdisciplinary meetings. The NP stated he would expect the nursing staff to do safety checks every 30 minutes of the resident to ensure no issues with circulation. An observation, on 02/23/18 at 2:14 PM, revealed Resident #14 in her room seated in her geri chair with the hand mitts on both hands. Resident #14 presented with a pleasant affect, made eye contact, and spoke, although nonsensical (having no meaning/making no sense). A review of Resident #14's ADL Records revealed nursing staff were initialing every 12 hour shift, 7 AM to 7 PM, and 7 PM to 7 AM, that every thirty minute safety checks, and every two hour releases of the hand mitts were being done. The ADL Record did not document each 30 minute check, or two hour release individually, just every shift. A review of the Nurse's Notes, dated 11/27/17, when the hand mitts were ordered, through 02/27/18, revealed nurses had documented regarding the resident being on every thirty minute safety checks with mitts in place on each 12 hour shift, but there were only four entries during that time period that indicated the resident had mitts released. One on 12/9/17, when she received incontinent care, one on 01/13/18 while the resident was receiving assistance with dressing, one on 01/14/18 when the nurse was cleaning a skin tear on the top of the resident's hand, and one on 01/20/18 when the nurse noted restraint reduction started. Bilateral mittens removed. Place on close observation. In geri chair in front of nurse desk. Fifteen minutes later on 01/20/18 at 9:00 AM, the nurse noted, Resident fidgety then started biting on left hand. Reduction ended. Gloves placed back on bilateral hands. An interview with the DON (Director of Nurses), on 02/27/18 at 2:00 PM, revealed the nursing staff should check on the resident every thirty minutes, and release the hand mittens every two hours for 10 minutes. The DON stated these interventions should be documented in the tracking record or nursing notes, and confirmed the tracking record only required one entry every shift, not every thirty minutes for checks, or two hours for release.

Based on policy/procedure review, record review and interview; the facility failed to ensure that two (2) of six (6) residents sampled (Resident #1 and Resident #2) were provided services necessary to avoid physical harm as evidenced by on 6/7/16 Certified Nurses Aide (CNA) #1 attempted to provide care to Resident #1 and failed to get assistance and as a result Resident #1 slid from the bed and fractured her Bilateral Lower Extremities (BLE) and on 6/15/16 Certified Nurses Aide (CNA) #2 attempted to provide care to Resident #2 and failed to get assistance and as a result Resident #2 slid from the bed and fractured his Right Lower Extremity (RLE). Findings include: Policy/Procedure review on 6/23/2016 of the facility's Abuse and Neglect Policy revealed a last revision dated October 2014. Page 3 of 7 of the Abuse/Neglect Policy revealed the definition of Neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. RESIDENT #1 Observation on 6/23/16 around 11:00 AM, revealed Resident #1 up in a Geri-chair with legs elevated with both legs in a full soft cast with Velcro closure. Resident #1 did not answer any questions and had confusion noted. Review of Resident #1's Daily Care Guide, dated 5/20/16, revealed all of her Activities of Daily Living (ADL)'s required two (2) people to assist with the exception of eating which requires one (1). The Care plan for ADL's revealed that Extensive assistance x two (2) with bed mobility, transfers, dressing, bathing, toileting and personal hygiene with an onset date of 5/19/16. Medical Records and an Incident Report review for the 6/7/16 incident, revealed that on 6/7/16 CNA #1 attempted to provide incontinent care without assistance, and Resident #1 began to slide off of the side of the bed. CNA #1 had asked for assistance but did not wait for the assistance to begin the ADL care. Resident #1's knees never touched the floor but her feet went straight out and were supporting her weight. CNA #1 yelled for help and Resident #1 was assisted to the floor by several staff members. Resident #1 was assessed and then lifted by staff back into the bed. Resident #1 then began to complain of right leg pain. A mobile x-ray was ordered and revealed a fractured right femur. The Nurse Practioner then ordered a transfer to the hospital. X-rays at the hospital revealed a left fractured femur also. Resident was then admitted to the hospital for surgical intervention. Review of the 6/7/16 handwritten statement by CNA #1 (did not return phone call) revealed she asked for help but the second CNA never came So I started changing (Resident #1). She also admitted I know she was a two person assist. Interview on 6/23/16 at 2:10 pm with Resident #1's Medical Doctor (MD), when asked about Resident #1's fractures, revealed, She is a two (2) person assist, especially when they are incontinent and unable to do for themselves. You can't predict what a patient is going to do, you just need some help. Interview on 6/24/16 at 11:00 AM with the Director of Nurses revealed, The CNA was suspended when the investigation was happening. She told the investigator she did it by herself. She told him she was doing ADL care by herself. She knew she was supposed to have 2 people. The DON stated, We teach CNA's about Care guides on hire, nurse competency, and we do inservices. Interview on 6/24/16 at 11:25 AM, with LPN Investigator revealed, CNA #1 told me she did ask for assist from another CNA but didn't wait for the help. She said to me she knew Resident #1 was a two (2) person assist but said she went ahead and got started without help. Record Review of Resident #1 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) prior to the 6/7/16 incident with an Assessment Reference Date (ARD) 5/11/16 for the Annual review revealed a Brief Interview for Mental Status (BIMS) of four (4), meaning Resident #1 rarely if ever made daily decisions and had severe cognitive impairment. RESIDENT #2 Observation an interview with Resident #2 on 6/23/16 at 11:45 AM, revealed My guy nurse let me fall down. When I fell , he fell . We were both on the floor. He was getting me dressed, I was sitting on the side of the bed. It broke my leg. Review of the ADL care plan revealed Resident #2 required 2 persons for assist with ADL care. Review of the 6/15/16 medical records and incident report for Resident #2 revealed that CNA #2 attempted to dress Resident #2 without the assistance of another staff member. Resident #2 was sitting on the side of the bed as CNA #2 was changing his shirt and Resident #2 began to slide off of the bed. CNA #2 attempted to assist the resident to the floor and they both fell to the floor with CNA #2 resting on top of Resident #2. CNA #2 went to get assistance. Resident #2 was assisted to bed with a Hoyer Lift. He began to complain of Right Knee pain. He was transferred to the hospital for further evaluation. X-ray of the Right Lower Extremity revealed fractures to the Right Tibia and Fibula. Resident was returned to the facility 6/15/16 with a Right Knee Immobilizer. Review of the written and signed statement of CNA #2 dated 6/15/16, revealed that CNA #2 failed to check the ADL care guide for Resident #2 prior to attempting to provide care to check the level of assistance required. An attempt was made by surveyor to interview CNA #2 by phone, however the CNA did not return the phone call. Interview with the MD for Resident #2 on 6/23/16 at 2:20 PM, revealed He doesn't have the ability to maneuver self, and two (2) person assist would be easier. He was a two (2)person assist with his ADL's when this happened. Interview with Registered Nurse #1 on 6/24/16 at 7:05 AM, revealed CNA #2 said he has sat Resident #2 on the side of the bed to change his shirt and he started to slide and he eased him to the floor. Resident #2 is a two (2) person assist. CNA #2 was by himself in there. She stated a hoyer lift and more staff were used to get Resident #2 back into bed. He was complaining of pain in his Right leg. Record review on 6/23/16 of Resident #2 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with an ARD of 4/4/2016, revealed a BIMS score of 14. Section G of the MDS also revealed that Resident #2 required two (2) persons to assist with dressing. Resident #2 was able to make daily decisions. Review of the MDS with an ARD of 01/26/2016 (most recent available from facility) documented that resident was a two (2) person assist with baths, dressing and toileting.

Based on Policy/Procedure review, interview, and record review the facility failed to provide care for two (2) of six (6) residents sampled (Resident #1, Resident #2) in accordance with each residents written plan of care, as evidenced by, on 6/7/16 Certified Nurses Aide (CNA) #1 failed to get assistance before attempting to provide care to Resident #1. This resulted in Resident #1 sliding from the bed and fracturing both Lower Extremities. On 6/15/16, Certified Nurses Aide (CNA) #2 failed to get assistance before attempting to provide care to Resident #2 and resulted in Resident #2 sliding from the bed and fracturing his Right Lower Extremity (RLE). Findings include: Policy/Procedure review of the facility's Interdisciplinary Care Plan, revised October 2013, revealed, Care will be provided as planned. (2) A Daily Care Guide to educate the Certified Nurse Assistant's regarding necessary interventions will be provided to the CNA responsible for the resident's care. The Daily Care Guide for each resident will be filed with the Activities of Daily Living (ADL) sheet. RESIDENT #1 Review of Resident #1's Daily Care Guide, dated 5/20/16, revealed all of her Activities of Daily Living (ADL)'s required two (2) people to assist with the exception of eating which requires 1. The Care plan for ADL's revealed that Extensive assistance x two (2) with bed mobility, transfers, dressing, bathing, toileting and personal hygiene, with the onset date of 5/19/16. Medical Records and an Incident Report review for the 6/7/16 incident revealed that on 6/7/16 CNA #1 attempted to provide incontinent care without assistance and Resident #1 began to slide off of the side of the bed. CNA #1 had asked for assistance but did not wait until the help arrived before attempting to deliver care. Resident #1's knees never touched the floor but her feet went straight out and were supporting her weight. CNA #1 yelled for help and Resident #1 was assisted to the floor by several staff members. Resident #1 was assessed and then lifted by staff back into the bed. Resident #1 then began to complain of right leg pain. A mobile x-ray was ordered and revealed a fractured right femur. The Nurse Practioner then ordered a transfer to the hospital. X-rays at the hospital revealed a left fractured femur also. Resident was then admitted to the hospital for surgical intervention. Review of the 6/7/16 handwritten statement by CNA #1 revealed she asked for help but the CNA never came so she started changing (Resident #1) on her own. CNA #1 also admitted she knew Resident #1 was a two (2) person assist. CNA #1 never returned the surveyor's phone call. Record Review on 6/23/16 of Resident #1 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) prior to the 6/7/16 incident with an Assessment Reference Date (ARD) 5/11/16 for the Annual review revealed a Brief Interview for Mental Status (BIMS) of four (4), meaning Resident #1 rarely if ever makes daily decisions. RESIDENT #2 Review of the ADL care plan with an onset date of 1/13/16 revealed Resident #2 required two (2) persons for assist with bed mobility, dressing, bathing and toileting. Review of the medical records and incident report for dated 6/15/16, for Resident #2, revealed that CNA #2 attempted to dress Resident #2 without the assistance of another staff member. Resident #2 was sitting on the side of the bed as CNA #2 was changing his shirt and Resident #2 began to slide off of the bed. CNA #2 attempted to assist the resident to the floor and they both fell to the floor with CNA #2 resting on top of Resident #2. CNA #2 got up and went to get help. He was assisted to bed with a Hoyer Lift and began to complain of Right Knee pain. He was then transferred to the hospital for further evaluation. X-ray of the Right Lower Extremity revealed fractures to the Right Tibia and Fibula. Resident was returned to the facility 6/15/16 in a Right Knee Immobilizer. Review of the written and signed statement of CNA #2 dated 6/15/16 revealed that CNA #2 reported failing to check the ADL care guide to check the level of assistance required for Resident #2 prior to attempting to provide care. A phone message was left for CNA #2 by surveyor, but no return call was made by CNA #2 for an interview. Interview with the Director of Nurses (DON) on 6/24/15 at 11:00 am revealed The Daily Care Guides are at each nurses station in a book for each resident. Interview with Registered Nurse #2 on 6/24/16 at 10:40 am revealed Care plans are updated daily with new orders and every three months with quarterly assessments. ADL guides are updated quarterly, annually and with significant change. CNA's will tell us if a resident has a decline and we adjust the ADL guide as necessary. We look through the ADL books at least one time a week to make sure the guide in in there and the ADL flow sheet is current. CNA's will tell us if a guide is missing and we reprint it. Record review on 6/23/16 of Resident #2 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with an ARD of 4/4/2016 revealed a BIMS score of 14 for Resident #2. He is able to make independent daily decisions. Section G of the MDS also revealed that Resident #2 required two (2) persons to assist with dressing. Resident #2 was able to make daily decisions. Review of the 01/26/2016 (most recent available from facility) has that Resident #2 is a two (2) person assist with baths, dressing and toileting.

Based on observation, interview, record review and policy review, the facility failed to develop a care plan with interventions related to safe transportation of residents for two (2) of five (5) residents reviewed for transportation as evidenced by Resident #1 fell from the lift van to the ground when the transport driver failed to assure the lift gate was in the upward position on 3/28/16; and Resident #3 fell from a Geri-Chair during transport to an off campus appointment on 4/27/16 that resulted in a Left Femur Fracture and Broken Nose. (Resident #1 and Resident #3) The facility's failure to develop and implement a Care Plan to use an approved mode of transportation and failure to follow facility policy caused serious injury to Resident #3 and that was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on 3/28/16. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on 5/5/16. An acceptable Allegation of Compliance (AoC) was received on 5/7/16. The State Survey Agency determined the Immediate Jeopardy was removed on 5/8/16 prior to exit on 5/9/16. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.20 (d) Resident Assessment (F279), 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 entitled, Interdisciplinary Care Plan, revised October 2013, revealed the facility will develop a written individualized care plan that meets the needs and choices of each resident as well as addresses the strengths, weaknesses and goals in order to enhance the quality of care provided. Resident #1 Record review of the Investigative Summary Report revealed Transport Driver #1 failed to assure the lift gate was in the upward position after letting another resident down and Resident #1 was pushed off the end of the transport van on 3/28/16. Transport Driver #1 failed to be on the ground while operating the lift that resulted in a fall with abrasions to the head for Resident #1. A review of Resident #1's Care Plan revealed the care plan failed to address the mode in which Resident #1 should be transported to off campus appointments to assure safety during transportation. Review of the facility's Care Card for Resident #1, revealed Resident #1 was mobile via cane/walker and wheelchair. An observation and interview with Resident #1 was attempted but Resident #1 was admitted to the hospital and remained there the duration of the survey for an unrelated concern. A post survey phone interview conducted with Resident #1 on 5/23/16 at 12:30PM, indicated he could not recall details of the event, but indicated he was not seriously hurt. Review of Resident #1's Face Sheet revealed the facility admitted Resident #1 on 10/14/15 with [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 3/23/16 revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #1 was cognitively intact. Resident #3 A review of Resident #3's Care Plan revealed the facility failed to develop the care plan to address the mode in which Resident #3 should be transported to off campus appointments to assure safety during transportation. In the record review of the facility's Investigative Summary Report for Resident #3 on 4/27/16 at 2:50 PM, revealed while en route to an off campus doctor's appointment, Transport Driver #2 applied brakes to stop, and Resident #3 slid out of the Geri-Chair, which was being used to transport Resident #3, onto the floor of the van. Resident #3 sustained a left Femur Fracture and a Broken Nose. LPN #1 was not in back of the van with Resident #3. The seat belt straps were in place and the chair straps were in place. Review of Resident #3's Care Card revealed no listed mode of transportation. Observation of Resident #3 on 5/4/16 at 5:30 PM revealed Resident #3 lying with the head of the bed elevated with two (2) half side rails up. Resident #3 was frail in appearance, had a Foley Catheter in place, and did not respond to the surveyor. Review of Resident #3's Face Sheet revealed the facility admitted Resident #3 on1/29/13 with the [DIAGNOSES REDACTED]. Resident #3's Significant Change In Status Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 4/20/16 revealed a Brief Interview for Mental Status (BIMS) of three (3), which indicated severe cognitive impairment. On 5/6/16 at 12:02 PM, an interview with the Director of Nursing (DON) revealed the Care Plans for Resident #1 and Resident #3 did not address a mode of transportation to be used during off campus transports and stated no care plan was needed until now. The DON stated that the mode of transportation to be used for each resident is the same as that used in the building and this is on the resident's Care Plan. The DON stated the facility had no previous concerns related to the use of Geri-Chairs during transport. The DON stated it is the CNA's responsibility to look at the Care Cards to see if a resident uses a wheelchair or a Geri-Chair when getting a resident ready for appointments and the Care Cards are generated from the Plan of Care for each resident. Interview with Certified Nursing Assistant (CNA) #2 on 5/5/16 at 2:10 PM revealed, The Care Card tells you how a resident is transported whether by wheelchair or Geri-Chair. Interview with CNA #3 on 5/5/16 at 3:30 PM, stated, the CNAs use, the Care Card to see what kind of chair the resident is transported in. Interview on 5/9/16 at 10:50 AM with the Medical Director, who attends Care Plan Meetings, revealed the facility reviews concerns in the Care Plan meetings that are identified in the daily stand up meetings, and incidents or accidents. During the Care Plan meeting the facility discusses in detail incidents/accidents, falls, behaviors and dementia.The Medical Director stated the Care Plan meetings consist of the DON, MDS/Care Plan Nurse, Dietary, and sometimes the resident or RP. Other Department Heads are present as needed. The Medical Director confirmed there was no Care Plan developed, prior to the incidents with Resident #1 and Resident #3, for how a resident was to be transported out of the facility. Interview with the MDS/Care Plan RN on 5/6/16 at 10:20 AM revealed the facility has never had to address on the care plan how a resident is transported off campus, we use whatever means is safe for the resident. MDS/Care Plan RN stated, the facility was never aware that it was not safe to use Geri-Chairs in the van for transport. In an interview with the Director of Rehabilitation on 5/6/16 at 8:38 AM revealed the therapist stated the therapy department attends the daily stand up meetings every morning and also the Care Plan meetings. The therapist stated Resident #3 was not assessed by the therapy department for the use of a Geri-Chair. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 5/7/16 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy. 1. This is the facility's Credible Allegation of Compliance (AoC) concerning two transportation incidents on March 28, 2016 involving Resident #1 and on April 27, 2016 involving Resident #3. 2. Description of Incident. Resident #1: March 28, 2016 at 9:20 AM- During an off campus doctor's appointment, Transportation Driver #1 reported that Resident #1 fell while in his wheelchair from the back of the lift van to the ground. Certified Nursing Assistant (CNA) #1 was accompanying staff during the transport. Resident #1 was sent to the local emergency room with a small laceration to the back of his head. Resident #3: April 27, 2016 at 2:50 PM- En route to an off campus doctor's appointment, Transportation Driver #2 reported that Resident #3 slid out of the Geri-Chair that was used to transport Resident #3 onto the floor of the lift van. Injuries related to the fall included a fractured nose and a fractured left femur. Licensed Practical Nurse (LPN) #1 was the accompanying staff during the transport. 3. Measures Implemented: Resident #1: March 28, 2016 at 9:30 AM- Nursing Manager contacted Hospital Director to notify him of the Resident #1 incident. Hospital Director gave directive to refer the incident to Investigative Services and the Quality Assurance Department. Resident #3: April 27, 2016 at 3:00 PM- Nursing Home Administrator contacted Hospital Director to notify him of the Resident #3 incident. Hospital Director gave a directive to the Nursing Home Administrator to suspend all transportation of residents requiring a Geri-Chair until the cause of the accident has been determined and to contact the local non-emergency ambulance service for future transportation of those residents. 4. Resident #1: March 29, 2016 at 9:00 AM- Quality Assurance Department requested a plan of correction from the Public Safety Director in regards to the Resident #1 incident. The Public Safety Director's plan of correction included immediately retraining all transportation drivers on the proper operation of the lift-van. Resident #3: April 27, 2016 at 3:10 PM- The Nursing Home Administrator notified the Public Safety Director and the Nurse Manager of the directive and to inform their staff. The Public Safety Director notified the transportation Supervisors of the directive and to inform their staff. 5. Policy Revision: Resident #1: There were no policy revisions for this incident. Resident #3: April 28, 2016 at 10:30 AM- Public Safety Director submitted a revision of Policy 305-03 Transportation of Individual Receiving Services to Policy and Procedure committee Chair to include staff sitting in the back of the van with the resident to observe, monitor and assist the residents. On May 5, 2016 at 11:00 AM, Public Safety Director submitted a second revision of Policy 305-03 Transportation of Individual Receiving Services to Policy and Procedure Committee. Revisions included the replacement of wheelchairs and geri-chairs with vehicle approved transport chairs. Both revisions were approved for implementation. 6. Training/In-services: Resident #1: March 29, 2016 at 10:00 AM- Transportation Supervisor trained all transportation drivers on proper use of operation of lift van. Transportation drivers were not allowed to operate the lift van until trained. No transportation staff was allowed to report to work until trained of the above mentioned. Resident #3: April 28, 2016 at 11:00 AM- Nurse Manager trained nursing staff (RN, LPN and CNA) that effective immediately staff must sit in the back of the van with residents when accompanying residents to monitor, observe and assist the resident during transport. On May 5, 2016 at 4:00 PM, Nurse Educator trained staff (Transportation driver, RN, LPN, Physicians, CNAs, Social Workers, Psychology Staff, Recreations, Direct Care Trainee, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) on the first and second revision of Policy 305-03 Transportation of Individual Receiving Services. No resident will be transported in Geri-Chairs. Only Vehicle approved transport chairs will be utilized. No staff was allowed to report to work until trained of the above mentioned. 7. Audits: Resident #1: April 8, 2016 at 10:00 AM- Public Safety Director implemented a Lift Van Operation Checklist audit form in the plan of correction to include each transportation drivers receiving (5) monthly audits for 90 days. Audits began on April 11, 2016 with a 100% compliance rate. Resident #3: Nursing Home Administrator has conducted audits to ensure compliance with the suspension of Geri-Chair transport since April 27, 2016. There have been no Geri-Chairs transported since April 27, 2016. 8. Disciplinary Actions: Resident #1: March 28, 2016 at 10:00 AM- Transportation Driver #1 was referred to Human Resources for disciplinary actions. Resident #3: There will be no staff disciplinary actions taken for Resident #3 Incident. It was determined that it was a system failure due to the use of a Geri-Chair that was not authorized for vehicle transport. 9. Notification of State Agencies: Resident #1: March 28, 2016 at 4:35 PM- Mississippi Department of Health and Mississippi Attorney General Office were notified of incident involving Resident #1. Resident #3: April 28, 2016 at 8:47 AM- Mississippi Department of Health and Mississippi Attorney General Office were notified of incident involving Resident #3. 10.Quality Assurance: Resident #1 and Resident #3: April 28, 2016 at 10:00 AM- Nursing Home Administrator met with the Safety Committee to discuss and examine the Geri-Chair involved in the incident. The sub-committee Safety Committee members include: Medical Services Director/Physician, Director of Public Safety Division/Risk Manager/Safety Committee Chair, Nursing Home Administrator, Assistant Hospital Director, Physical Plan Director, Nurse Executive, Director of Nursing, Director of Accreditation, Maintenance Worker, RN Nurse Supervisor, Certified Nursing Assistant, and Nursing Home Administrator. The sub-committee supported the directive of suspending transport of residents in Geri-Chairs. It was recommended to purchase a vehicle approved transport chair. April 29, 2016 at 3:00 PM- Public Safety Director submitted a description of a vehicle approved transport chair to Business Services. A purchase requisition was submitted and approved on 5/4/16 for a vehicle approved transport chair. May 5, 2016 at 3:23 PM- Quality Assurance committee met to discuss the incident involving Resident #1 and Resident #3. The members of the QA Committee include: Nursing Home Administrator, Outcome Services Division Director, RN/Quality Assurance Nurse, Medical Services Director/Physician, Director of Nursing, RN/Nurse Educator, Certified Nursing Assistant Supervisor, Risk Manager/Director of Public Safety, RPW Nursing Home Administrator, Professional Development/Policy Management Director, RN Nurse Supervisor, LPN Nurse Educator, RN/Investigative Services. The QA Committee implemented the following changes: 1. Revision of Policy 305-03 Transportation of Individual Receiving Services. Wheelchairs and Geri-Chairs was deleted from the policy and replaced with vehicle approved transport chairs. 2. Revision of Lift Van Operation Checklist audit form. Wheelchairs and Geri-Chairs was deleted for the form and replaced with vehicle approved transport chairs. 3. Suspension of transporting residents until completion of training on the revision in Policy 305-03 Transportation of Individual Receiving Services. 4. Effective immediately on 5/5/16 at 3:30 PM, until completion of training on Policy 305-03 Transportation of Individual Receiving Services, the transportation of all residents was suspended. 5. Staff (Transportation Staff, RN, LPN, CNA, Physicians, Social Workers, Psychology Staff, Recreation, Direct Care Trainees, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) will not be able to work until trained. 11.Removal of Immediate Jeopardy: All Activities to remove the immediate jeopardy have been accomplished on 5/7/16 and the facility alleges that the removal of the immediate jeopardy was effective as of 5/8/16. This Credible AoC was signed by the facility Administrator on 5/7/16 at 1:30 PM. On 5/9/16, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable Credible Allegation of Compliance was verified by staff interviews and record review of in-services on March 29, 2016 at 10:00 AM, the Transportation Supervisor trained all transportation drivers on proper use and operation of the lift van. On April 28, 2016 at 11:00 AM, the Nurse Manager trained the nursing staff (RNs, LPNs and CNAs) that staff must sit in the back of the van with residents when accompanying residents to monitor, observe and to assist the resident during transport. On May 5, 2016 at 4:00 PM, the Nurse Educator trained staff (Transportation driver, RN, LPN, Physicians, CNAs, Social Workers, Psychology Staff, Recreations, Direct Care Trainee, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) on the first and second revision of Policy 305-03, Transportation of Individual Receiving Services, and that no resident will be transported in Geri-Chairs and only Vehicle approved transport chairs will be utilized. All staff, across all disciplines were trained, except seven (7) that were off on medical leave or vacation, but would not be allowed to work until trained. These interviews included RNs, LPNs, CNAs, Social Services Staff, Activities Staff, Health Information Staff, Admissions/Marketing Director, Dietary Staff, Housekeeping/Laundry Staff, Maintenance Staff, Business Office Staff, Director of Nursing, Transportation Drivers, Director of Public Safety and the Facility Administrator. The content of the in-services held on March 29, 2016 at 10:00 AM, April 28, 2016 at 11:00 AM and May 5, 2016 at 4:00 PM were verified during each interview. Six (6) RNs, eight (8)LPNs, twenty-one (21) CNAs, two (2) Social Services Staff, one (1) Activities Staff, two (2) Health Information Staff, one (1) Admissions/Marketing staff, one (1) Dietary Staff, seven (7) Housekeeping/Laundry Staff, three (3) Maintenance Staff, two (2) Business Office/Health Information Staff, Director of Nursing, three (3) Transportation Drivers verified being in-serviced on the facility's policy/procedures for transporting residents and that no resident will be transported in a Geri-Chair or Wheelchair only a vehicle approved transport chair, staff accompanying residents on transport are to sit in the back with the residents at all times. Three (3) Transportation Drivers verified they received an in-service on the facility's policy/procedure for proper use and operation of the lift van. Review of the Disciplinary Action for Transportation Driver #1 revealed Transportation Driver #1 was suspended from work and received a written reprimand for violation of safety rules dated 4/4/16. Review of the State Agency Complaint intake form revealed the facility reported the incident to the State Agency involving Resident #1 on 4/22/16, and Resident #3 on 4/28/16 and sent full investigative report on 5/5/16. Review of the Quality Assurance meeting dated 5/5/16 confirmed the meeting consisted of covering the incident involving Resident #1 and Resident #3. The QA Committee implemented the following changes: 1. Revision of Policy 305-03 Transportation of Individual Receiving Services. Wheelchairs and Geri-Chairs was deleted from the policy and replaced with vehicle approved transport chairs. 2. Revision of Lift Van Operation Checklist audit form. Wheelchairs and Geri-Chairs was deleted for the form and replaced with vehicle approved transport chairs. 3. The suspension of transporting residents until completion of training on the revision in Policy 305-03 Transportation of Individual Receiving Services. 4. Effective immediately on 5/5/16 at 3:30 PM, until completion of training on Policy 305-03 Transportation of Individual Receiving Services, the transportation of all resident was suspended. 5. Staff (Transportation Staff, RN, LPN, CNA, Physicians, Social Workers, Psychology Staff, Recreation, Direct Care Trainees, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) will not be able to work until trained. Record review revealed the Lift Van Operation Checklist audits had 100% compliance, from 4/11/16 to 5/5/16 that was completed by the Transportation Supervisor. The QA committee recommended the purchase of a vehicle approved transport chair and supported the directive of suspending transport of residents in Geri-Chairs. Record review of a Purchase Order (PO) requisition for a transport approved chair that has been crash tested to meet the WC-19 standards for occupant transport, with the PO number of was issued on 5/4/16 after approval was obtained. The State Agency Surveyor reviewed the revised policies submitted by the Public Safety Director, Policy 305-03 Transportation of Individual Receiving Services to Policy and Procedure committee Chair to include staff sitting in the back of the van with the resident to observe, monitor and assist the residents. On May 5, 2016 at 11:00 AM, Public Safety Director submitted a second revision of Policy 305-03 Transportation of Individual Receiving Services to Policy and Procedure Committee. Revisions included the replacement of wheelchairs and geri-chairs with vehicle approved transport chairs. Both revisions were approved for implementation.

Based on observation, interview, record review, policy review, and facility investigation review, the facility failed to review and revise transportation policies and procedures and failed to provide safe transportation of residents for two (2) of five (5) residents reviewed for van transport as evidenced by on [DATE], facility transportation staff failed to assure a lift gate was in the up position prior to pushing Resident #1 out of the van to the ground and on [DATE], failed to use a chair approved for transport of a resident according to manufacturer's recommendations. The facility's failure to revise the transportation policy after the first incident with Resident #1, and failure to identify that Geri-Chairs were not approved by the manufacturer for transport resulted in Resident #3 being thrown out of a Geri-Chair on [DATE] during transport, and resulted in a left Femur Fracture and Broken Nose for Resident #3 and caused a situation that was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE]. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] prior to exit on [DATE]. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.25 (h) Quality of Care (F323), 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 entitled, Transportation of Individuals Receiving Services revealed the latest revision date of [DATE] to require accompanying staff to sit with the resident in the back of the vehicle to assist as needed. When this policy was reviewed by the Policy and Procedure Committee and the Safety Committee, on [DATE], the facility failed to identify the unsafe use of Geri-Chairs for van transportation and failed to remove the use of the Geri-Chairs for transport from the policy; therefore, placing all residents transported in the van in a Geri-Chair at risk. The manufacturer's instructions for Geri-Chairs revealed a Warning that read, DO NOT use recliner for Transporting in or with ANY type of vehicle or trailer. The (name brand) recliners, have not been tested or approved for use by an occupant in any type of vehicle or trailer. Resident #3 Record review of the facility's Investigative Summary Report for Resident #3, dated [DATE] at 2:50 PM, revealed Transport Driver #2 and LPN #1 assisted Resident #3 to an off campus doctor's appointment. While en route, Transport Driver #2 applied brakes to stop and Resident #3 slid out of the Geri-Chair with the seat belt straps in place and the chair straps in place. Resident #3 sustained a left Femur Fracture and a Broken Nose. LPN #1 was sitting in the front passenger seat at the time of the incident and was unable to stop Resident #3 from sliding out of the chair. There was no other facility staff in the back of the van to assist the resident. On [DATE] at 11:00 AM, an interview with Transport Driver #2 revealed on [DATE] at 2:50 PM, Resident #3 slid out of the Geri-Chair onto the floor of the van, when I put on brakes. Transport Driver #2 stated the Geri-Chair remained in place and the seat belt straps were still in place when Resident #3 slid out under the straps. The nurse (Licensed Practical Nurse (LPN) #1) was in the front seat when Resident #3 slid out. The SA surveyor attempted an interview with Licensed LPN #1 three (3) times during the survey without success. In a phone interview with Resident #3's Responsible Party (RP) on [DATE] at 4:40 PM, stated the facility notified her of Resident #3's fall in the van. Resident #3's RP stated there had been no previous concerns with falls during transportation. Resident #3's RP stated Resident #3 was now on Hospice for comfort measures only because Resident #3 had declined so much since the surgery after the fall in the van. Review of the hospital admission history and physical, dated [DATE], revealed the hospital admitted the resident with a left femoral shaft fracture. Review of Resident #3's operative note revealed the resident required a retrograde intramedullary nailing of the left femur. The discharge summary for Resident #3, dated [DATE], revealed resident was discharged back to the facility on [DATE]. (Resident #3 died in the facility on [DATE]). Observation of Resident #3 on [DATE] at 5:30 PM revealed Resident #3 in bed with the head of the bed elevated with two (2) half side rails up and the television was on in the room. Resident #3 with eyes open but did not respond to the surveyor. Resident #3 had a Foley Catheter, and was frail. Interview with the Director of Nursing (DON) on [DATE] at 10:12 AM revealed Resident #3 was not able to be interviewed and now was on Hospice services because of a decline in condition after the recent injuries. Interview with the Director of Rehabilitation on [DATE] at 8:38 AM revealed the facility initially would screen each resident on admission for evaluation for assistive devices, positioning devices or other therapy needs. If there was a change in the resident's condition, the therapy department may be consulted by the Nurse Practitioner (NP) or the nurses to do an evaluation. Every morning staff from therapy would attend the daily stand up meetings and if a resident had a concern with falls, a follow-up would be done. The therapist stated that bed bound residents are placed in a Geri-Chair when the facility gets them out of bed and this can be just the nurses decision. The therapist stated the therapy department is not involved in decisions regarding transportation, unless a resident needs a modification for being transported. The therapist stated Resident #3 was not assessed by the therapy department for the use of a Geri-Chair. On [DATE] at 12:02 PM, an interview with the Director of Nursing (DON) revealed the facility had been using Geri-Chairs for transportation for at least ten (10) years. The DON stated, The manufacturers recommendations had not been reviewed until yesterday. The DON stated the facility's transportation policy reflected the use of Geri-Chairs during transport until now. In an interview on [DATE] at 3:00 PM with the facility Administrator, he agreed the facility's policy for transportation and the use of the Geri-Chair during transportation was not according to the manufacturer's recommendations and stated the policy, may be from years ago. Interview with the facility Administrator on [DATE] at 1:05 PM revealed the facility had used Geri-Chairs for transportation for at least ten (10) years. The Administrator stated he was not sure who started using them, but it has been accepted practice since he was hired. The Administrator stated it was not realized as deficient practice until the State Agency Surveyor requested the manufacturer's instructions on [DATE] and it was reviewed and then the facility recognized the Geri-Chair was not safe for use in the transportation van. Interview with the Medical Director on [DATE] at 10:50 AM revealed the facility had always used Geri-Chairs during transport but that all equipment would be looked at for closer inspection related to safety concerns. The Medical Director stated, I don't know why it took that long for something to happen. All residents will be transported via local ambulance service non-emergent transport until further notice, and the new transport chair arrives. The Medical Director stated he had been the Medical Director for eight (8) years and the Geri-Chairs have been used for transportation as long as he had been there. Review of the Transportation of Individuals Receiving Services policy revealed the policy dated back to a revision date of February 2014 for the use of Geri-Chairs. In an interview on [DATE] at 2:55 PM, the Public Safety Director revealed the policy and procedure was reviewed and revised on [DATE] after the incident on [DATE] involving Resident #3 but the manufacturer's recommendations for the Geri-Chair was not reviewed at that time, so the use of the Geri-Chair remained in the policy. On [DATE] at 10:05 AM, an interview with the Director of Public Safety revealed Resident #3 was in the back of the transport van in a Geri-Chair during transport for an off campus appointment on [DATE] at 2:50 PM. Transport Driver #2 braked at a stop sign and the back of the Geri-Chair came up causing Resident #3 to slid from underneath the seat belt and onto the floor of the van. The Director of Public Safety stated during the investigation it was determined that LPN #1 was in the front seat of the transport van and not in the back with Resident #3 at the time of the accident. The Director of Public Safety then stated it was not policy for staff to sit in the back of the van with the residents during transport. Interview with the Public Safety Director on [DATE] at 10:35 AM revealed the transportation policy was changed on [DATE] to include staff sitting in the back of the van with the resident at all times and wheelchairs and Geri-Chairs was changed to say, vehicle approved transport chairs. Both policy revisions were approved. On [DATE] at 9:00 AM, an interview with Investigative Services Registered Nurse (IS-RN) revealed the Safety Committee reviewed the incident involving Resident #3 and the facility is not using Geri-Chairs any longer for transport of residents. IS-RN stated, We are looking at where we had a process failure, how did this get passed to use a Geri-Chair during transportation. IS-RN stated a chair approved for transportation has been ordered. Review of Resident #3's Face Sheet revealed the facility admitted Resident #3 on [DATE] with the [DIAGNOSES REDACTED]. Resident #3's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) of five (5), which indicated severe cognitive impairment. Resident #3's Significant Change In Status Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) of three (3), which indicated severe cognitive impairment. Resident #3 had a decline from the previous assessment of BIMS of five (5) to a BIMS of three (3). The [DATE] assessment also indicated a decline in Resident #3's ability to transfer requiring more assistance and revealed the resident now required an Indwelling Urinary Catheter. According to the MDS review, Resident #3 also had a weight loss from 151 pounds on the [DATE] assessment to 143 pounds on the assessment of [DATE]. Resident #1 Record review of the Investigative Summary Report revealed Resident #1 was pushed off the end of the transport van when Transport Driver #1 failed to assure the lift gate was in the upward position after letting another resident down. Transport Driver #1 also failed to be on the ground while operating the lift, instead of in the back of the van that resulted in a fall with abrasions to the head for Resident #1. On [DATE] at 10:05 AM, an interview with the Director of Public Safety revealed the Transport Driver #1 did not operate the lift correctly when he failed to exit the van and stand at ground level outside of the van when unloading the resident. The Director of Public Safety explained while standing in the van with the resident, Transport Driver #1 pushed Resident #1 from the transport van onto the ground on [DATE] at 9:20 AM. The Certified Nursing Assistant (CNA) #1, who was supposed to assist in Resident #1's van exit, was at the passenger side door of the van when the incident occurred and not in the back of the van. On [DATE] at 11:10 AM, an interview with CNA #1 revealed on [DATE], while transporting Resident #1 and another resident to a doctor's appointment off campus, Transport Driver #1 assisted the other resident off the van first, then CNA #1 loosened the straps of the wheelchair on the right side of Resident #1's chair while the Transport Driver #1 was in the back with Resident #1. CNA #1 stated she then went back to the front seat of the van to drink a soda when she heard a boom. CNA #1 stated she then walked to the back of the transport van to find Resident #1 and Transport Driver #1 both on the ground. CNA #1 stated she should have been inside the van pushing the wheelchair and Transport Driver #1 should have been on the ground at the back of the van. CNA #1 stated she was not sure why Transport Driver #1 was not on the ground operating the lift and said, He should have been on the ground, operating the lift from the ground. On [DATE] at 3:00 PM, an interview with Transport Driver #1 revealed on [DATE] at 9:20 AM, he transported two (2) residents to the local hospital wound care clinic. Transport Driver #1 stated he unloaded the first resident with a CNA from the other facility and got into the back of the van with Resident #1. Transport Driver #1 stated CNA #1 unhooked the right side strap and returned to the front passenger seat to drink a soda when he pushed Resident #1 to the back of the van not realizing the lift was still in the down position. The Transport Driver #1 stated when he realized the lift was in the down position, it was too late to stop the wheelchair from going over the end of the van, and he went out the end of the van to the ground with Resident #1 while still holding onto the wheelchair. Transport Driver #1 stated the driver should have been on the ground to operate the lift and would have known the lift was down. Transport Driver #1 stated he was suspended and was written up for not following policy and procedure and stated, I don't know how in the world I could have forgot. Record review of a written reprimand for violation of safety rules when the Transport Driver #1 failed to put the lift gate back up, resulting in you and the resident falling out of the van onto the ground in reference to Resident #1 falling from the van on [DATE] at 9:20 AM and was signed by Transport Driver #1 on [DATE]. An observation and interview with Resident #1 was attempted during survey, but Resident #1 remained in the hospital the duration of the survey for an unrelated concern. A post survey phone interview was conducted with Resident #1 on [DATE] at 12:30PM regarding the fall from the facility van. He stated, I'm fine, not hurt or anything, but could not give any details of the event. Review of Resident #1's Face Sheet revealed the facility admitted Resident #1 on [DATE] with the [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #1 was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance (AoC) on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy. 1. This is the facility's Credible Allegation of Compliance (AoC) concerning two transportation incidents on [DATE] involving Resident #1 and on [DATE] involving Resident #3. 2. Description of Incident. Resident #1: [DATE] at 9:20 AM- During an off campus doctor's appointment, Transportation Driver #1 reported that Resident #1 fell while in his wheelchair from the back of the lift van to the ground. Certified Nursing Assistant (CNA) #1 was accompanying staff during the transport. Resident #1 was sent to the local emergency room with a small laceration to the back of his head. Resident #3: [DATE] at 2:50 PM- En route to an off campus doctor's appointment, Transportation Driver #2 reported that Resident #3 slid out of the Geri-Chair that was used to transport Resident #3 onto the floor of the lift van. Injuries related to the fall included a fractured nose and a fractured left femur. Licensed Practical Nurse (LPN) #1 was the accompanying staff during the transport. 3. Measures Implemented: Resident #1: [DATE] at 9:30 AM- Nursing Manager contacted Hospital Director to notify him of the Resident #1 incident. Hospital Director gave directive to refer the incident to Investigative Services and the Quality Assurance Department. Resident #3: [DATE] at 3:00 PM- Nursing Home Administrator contacted Hospital Director to notify him of the Resident #3 incident. Hospital Director gave a directive to the Nursing Home Administrator to suspend all transportation of residents requiring a Geri-Chair until the cause of the accident has been determined and to contact the local non-emergency ambulance service for future transportation of those residents. 4. Resident #1: [DATE] at 9:00 AM- Quality Assurance Department requested a plan of correction from the Public Safety Director in regards to the Resident #1 incident. The Public Safety Director's plan of correction included immediately retraining all transportation drivers on the proper operation of the lift-van. Resident #3: [DATE] at 3:10 PM- The Nursing Home Administrator notified the Public Safety Director and the Nurse Manager of the directive and to inform their staff. The Public Safety Director notified the transportation Supervisors of the directive and to inform their staff. 5. Policy Revision: Resident #1: There were no policy revisions for this incident. Resident #3: [DATE] at 10:30 AM- Public Safety Director submitted a revision of Policy ,[DATE] Transportation of Individual Receiving Services to Policy and Procedure committee Chair to include staff sitting in the back of the van with the resident to observe, monitor and assist the residents. On [DATE] at 11:00 AM, Public Safety Director submitted a second revision of Policy ,[DATE] Transportation of Individual Receiving Services to Policy and Procedure Committee. Revisions included the replacement of wheelchairs and geri-chairs with vehicle approved transport chairs. Both revisions were approved for implementation. 6. Training/In-services: Resident #1: [DATE] at 10:00 AM- Transportation Supervisor trained all transportation drivers on proper use of operation of lift van. Transportation drivers were not allowed to operate the lift van until trained. No transportation staff was allowed to report to work until trained of the above mentioned. Resident #3: [DATE] at 11:00 AM- Nurse Manager trained nursing staff (RN, LPN and CNA) that effective immediately staff must sit in the back of the van with residents when accompanying residents to monitor, observe and assist the resident during transport. On [DATE] at 4:00 PM, Nurse Educator trained staff (Transportation driver, RN, LPN, Physicians, CNAs, Social Workers, Psychology Staff, Recreations, Direct Care Trainee, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) on the first and second revision of Policy ,[DATE] Transportation of Individual Receiving Services. No resident will be transported in Geri-Chairs. Only Vehicle approved transport chairs will be utilized. No staff was allowed to report to work until trained of the above mentioned. 7. Audits: Resident #1: [DATE] at 10:00 AM- Public Safety Director implemented a Lift Van Operation Checklist audit form in the plan of correction to include each transportation drivers receiving (5) monthly audits for 90 days. Audits began on [DATE] with a 100% compliance rate. Resident #3: Nursing Home Administrator has conducted audits to ensure compliance with the suspension of Geri-Chair transport since [DATE]. There have been no Geri-Chairs transported since [DATE]. 8. Disciplinary Actions: Resident #1: [DATE] at 10:00 AM- Transportation Driver #1 was referred to Human Resources for disciplinary actions. Resident #3: There will be no staff disciplinary actions taken for Resident #3 Incident. It was determined that it was a system failure due to the use of a Geri-Chair that was not authorized for vehicle transport. 9. Notification of State Agencies: Resident #1: [DATE] at 4:35 PM- Mississippi Department of Health and Mississippi Attorney General Office were notified of incident involving Resident #1. Resident #3: [DATE] at 8:47 AM- Mississippi Department of Health and Mississippi Attorney General Office were notified of incident involving Resident #3. 10.Quality Assurance: Resident #1 and Resident #3: [DATE] at 10:00 AM- Nursing Home Administrator met with the Safety Committee to discuss and examine the Geri-Chair involved in the incident. The sub-committee Safety Committee members include: Medical Services Director/Physician, Director of Public Safety Division/Risk Manager/Safety Committee Chair, Nursing Home Administrator, Assistant Hospital Director, Physical Plan Director, Nurse Executive, Director of Nursing, Director of Accreditation, Maintenance Worker, RN Nurse Supervisor, Certified Nursing Assistant, and Nursing Home Administrator. The sub-committee supported the directive of suspending transport of residents in Geri-Chairs. It was recommended to purchase a vehicle approved transport chair. [DATE] at 3:00 PM- Public Safety Director submitted a description of a vehicle approved transport chair to Business Services. A purchase requisition was submitted and approved on [DATE] for a vehicle approved transport chair. [DATE] at 3:23 PM- Quality Assurance committee met to discuss the incident involving Resident #1 and Resident #3. The members of the QA Committee include: Nursing Home Administrator, Outcome Services Division Director, RN/Quality Assurance Nurse, Medical Services Director/Physician, Director of Nursing, RN/Nurse Educator, Certified Nursing Assistant Supervisor, Risk Manager/Director of Public Safety, RPW Nursing Home Administrator, Professional Development/Policy Management Director, RN Nurse Supervisor, LPN Nurse Educator, RN/Investigative Services. The QA Committee implemented the following changes: 1. Revision of Policy ,[DATE] Transportation of Individual Receiving Services. Wheelchairs and Geri-Chairs was deleted from the policy and replaced with vehicle approved transport chairs. 2. Revision of Lift Van Operation Checklist audit form. Wheelchairs and Geri-Chairs was deleted for the form and replaced with vehicle approved transport chairs. 3. Suspension of transporting residents until completion of training on the revision in Policy ,[DATE] Transportation of Individual Receiving Services. 4. Effective immediately on [DATE] at 3:30 PM, until completion of training on Policy ,[DATE] Transportation of Individual Receiving Services, the transportation of all residents was suspended. 5. Staff (Transportation Staff, RN, LPN, CNA, Physicians, Social Workers, Psychology Staff, Recreation, Direct Care Trainees, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) will not be able to work until trained. 11.Removal of Immediate Jeopardy: All Activities to remove the immediate jeopardy have been accomplished on [DATE] and the facility alleges that the removal of the immediate jeopardy was effective as of [DATE]. This Credible AoC was signed by the facility Administrator on [DATE] at 1:30 PM. On [DATE], the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable Credible Allegation of Compliance was verified by staff interviews and record review of in-services done on [DATE] at 10:00 AM, the Transportation Supervisor trained all transportation drivers on proper use and operation of the lift van. On [DATE] at 11:00 AM, the Nurse Manager trained the nursing staff (RNs, LPNs and CNAs) that staff must sit in the back of the van with residents when accompanying residents to monitor, observe and to assist the resident during transport. On [DATE] at 4:00 PM, the Nurse Educator trained staff (Transportation driver, RN, LPN, Physicians, CNAs, Social Workers, Psychology Staff, Recreations, Direct Care Trainee, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) on the first and second revision of Policy ,[DATE], Transportation of Individual Receiving Services, and that no resident will be transported in Geri-Chairs and only Vehicle approved transport chairs will be utilized. All staff, across all disciplines were trained, except seven (7) that were off on medical leave or vacation but would not be allowed to work until trained. These interviews included RNs, LPNs, CNAs, Social Services Staff, Activities Staff, Health Information Staff, Admissions/Marketing Director, Dietary Staff, Housekeeping/Laundry Staff, Maintenance Staff, Business Office Staff, Director of Nursing, Transportation Drivers, Director of Public Safety and the Facility Administrator. The content of the in-services held on [DATE] at 10:00 AM, [DATE] at 11:00 AM and [DATE] at 4:00 PM were verified during each interview. Six (6) RNs, eight (8)LPNs, twenty-one (21) CNAs, two (2) Social Services Staff, one (1) Activities Staff, two (2) Health Information Staff, one (1) Admissions/Marketing staff, one (1) Dietary Staff, seven (7) Housekeeping/Laundry Staff, three (3) Maintenance Staff, two (2) Business Office/Health Information Staff, Director of Nursing, three (3) Transportation Drivers verified being in-serviced on the facility's policy/procedures for transporting residents and that no resident will be transported in a Geri-Chair or Wheelchair only a vehicle approved transport chair, staff accompanying residents on transport are to sit in the back with the residents at all times. Three (3) Transportation Drivers verified they received an in-service on the facility's policy/procedure for proper use and operation of the lift van. Review of the Disciplinary Action for Transportation Driver #1 revealed Transportation Driver #1 was suspended from work and received a written reprimand for violation of safety rules dated [DATE]. Review of the State Agency Complaint intake form revealed the facility reported the incident involving Resident #1 on [DATE]; and Resident #3 on [DATE] and submitted the complete investigation on [DATE]. Review of the Quality Assurance meeting dated [DATE] confirmed the meeting consisted of covering the incident involving Resident #1 and Resident #3. The QA Committee implemented the following changes: 1. Revision of Policy ,[DATE] Transportation of Individual Receiving Services. Wheelchairs and Geri-Chairs was deleted from the policy and replaced with vehicle approved transport chairs. 2. Revision of Lift Van Operation Checklist audit form. Wheelchairs and Geri-Chairs was deleted for the form and replaced with vehicle approved transport chairs. 3. The suspension of transporting residents until completion of training on the revision in Policy ,[DATE] Transportation of Individual Receiving Services. 4. Effective immediately on [DATE] at 3:30 PM, until completion of training on Policy ,[DATE] Transportation of Individual Receiving Services, the transportation of all resident was suspended. 5. Staff (Transportation Staff, RN, LPN, CNA, Physicians, Social Workers, Psychology Staff, Recreation, Direct Care Trainees, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) will not be able to work until trained. Record review revealed the Lift Van Operation Checklist audits had 100% compliance, from [DATE] to [DATE] that was completed by the Transportation Supervisor. The QA committee recommended the purchase of a vehicle approved transport chair and supported the directive of suspending transport of residents in Geri-Chairs. Record review of a Purchase Order (PO) requisition for a transport approved chair that has been crash tested to meet the WC-19 standards for occupant transport, with the PO number of was issued on [DATE] after approval was obtained. The State Agency Surveyor reviewed the revised policies submitted by the Public Safety Director, Policy ,[DATE] Transportation of Individual Receiving Services to Policy and Procedure committee Chair to include staff sitting in the back of the van with the resident to observe, monitor and assist the residents. On [DATE] at 11:00 AM, Public Safety Director submitted a second revision of Policy ,[DATE] Transportation of Individual Receiving Services to Policy and Procedure Committee. Revisions included the replacement of wheelchairs and geri-chairs with vehicle approved transport chairs. Both revisions were approved for implementation.

Based on observation, interview, record review, policy review and facility investigation review, the facility failed to identify deficient practice and implement corrective actions as evidenced by the QA Committee's failure to identify the use of Geri-Chairs for transport in the facility's policy, after policy revision following a fall involving Resident #1. This resulted in a fall on 4/27/16 with major injuries for Resident #3 for two (2) of five (5) residents reviewed for off campus transportation. The facility failed to identify that the use of Geri-Chair for transportation of residents to off campus appointments was against manufacturer's guidelines and failed to provide safe transportation for Resident #3 that resulted in a fall from a Geri-Chair during transport on 4/27/16 at 2:50 PM that resulted in a Left Femur Fracture and Broken Nose. The Manufacturer's Recommendations indicated the Geri-Chair was not safe to be used in transportation in a vehicle. The facility's failure to use an approved mode of transportation caused a situation that was likely to cause serious injury, harm, impairment or death to other residents. This situation was determined to be an Immediate Jeopardy (IJ) which began on 3/28/16 when the facility failed to recognize safety concerns with the transportation policy. The facility's Administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on 5/5/16. An acceptable Allegation of Compliance (AoC) was received on 5/7/16 in which the facility alleged the Immediate Jeopardy was removed on 5/8/16. The State Survey Agency determined the Immediate Jeopardy was removed on 5/8/16 prior to exit on 5/9/16. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.75 (o) (1) Administration (F520), 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 entitled, Quality Assurance, revised October 2013 revealed it is the policy of the facility to coordinate a Quality Assurance (QA) Program through comprehensive and continuous monitoring of activities that measure and assess the care and services provided to its residents in order to promote the optimal well-being of those it serves and to ensure compliance with state and federal regulations. The manufacturer's instructions for the Geri-Chair revealed the Warning, stated, DO NOT use recliner for Transporting in or with ANY type of vehicle or trailer. The (name brand) recliners have not been tested or approved for use by an occupant in any type of vehicle or trailer. Resident #3 Record review of the facility's Investigative Summary Report for Resident #3 on 4/27/16 at 2:50 PM, revealed Resident #3 slid out of the Geri-Chair onto the floor of the van and sustained a Left Femur Fracture and a Broken Nose when Transport Driver #2 applied brakes to stop while being transported to an off campus doctor's appointment. LPN #1 was not in back of the van with Resident #3 when the accident occurred. The seat belt straps were in place across the chest and lap of Resident #3 and the chair straps were in place. Record review of the facility's incident and investigation report for Resident #3 revealed Resident #3 slid out of the Geri-Chair during a routine transport to an off campus doctor's appointment when the Transport Driver #2 applied the brakes to stop on 4/27/16 at 2:50 PM. Resident #3 sustained a Left Fractured Femur and a Broken Nose. In an observation of Resident #3 on 5/4/16 at 5:30 PM revealed Resident #3 did not respond when spoken to but had eyes open. Resident #3 had a Foley Catheter at the bedside and was frail in appearance. Resident #1 Record review of the Investigative Summary Report revealed Transport Driver #1 failed to assure the lift gate was in the upward position after letting another resident down and Resident #1 was pushed off the end of the transport van and fell to the ground on 3/28/16. Transport Driver #1 failed to be on the ground while operating the lift that resulted in a fall with abrasions to the head for Resident #1. On 5/6/16 at 9:00 AM, an interview with Investigative Services Registered Nurse (IS-RN) stated the Safety Committee meeting on 4/28/16 (Quality Assurance (QA) Committee members present) met and changes have been made that all transportation for resident in both buildings have been stopped until all in-services have been completed and Geri-Chairs are no longer used in transportation, only vehicle approved chairs can be used. Record review revealed the facility had a Safety Committee meeting on 4/28/16 (with members of the QA Committee to include the Medical Director, DON, Administrator, MDS/Care Plan Nurse and Nursing Supervisors) discussed and reviewed the transportation policy but did not remove the use of transporting residents in Geri-Chairs. The QA Committee met on 4/20/16 after the incident when Resident #1 fell off the end of the transport van with minor injuries. The facility QA failed to identify the use of Geri-Chairs as deficient practice and on review of the Policy 305-03, Transportation of Individual Receiving Services, during this meeting, failed to identify the facility's use of a Geri-Chair during transport being listed as acceptable practice in this policy. Interview with the Medical Director on 5/9/16 at 11:06 AM revealed the facility had a QA meeting/Safety Committee meeting on 4/28/16 to discuss the incident involving Resident #1 after the accident on 4/27/16 and confirmed the transportation policy was reviewed, but the committee did not identify the use of the Geri-Chair during transport as a concern at that point. Interview with the Public Safety Director on 5/9/16 at 10:35 AM revealed the transportation policy was changed on 4/20/16 to include staff sitting in the back of the van with the resident at all times. During the Safety Committee meeting on 4/28/16, after the incident with Resident #1, the facility failed to change the policy to remove the use of Geri-Chairs. Review of Resident #1's Face Sheet revealed the facility admitted Resident #1 on 10/14/15 with the [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 3/23/16 revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #1 was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 5/7/16 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy. 1. This is the facility's Credible Allegation of Compliance (AoC) concerning two transportation incidents on March 28, 2016 involving Resident #1 and on April 27, 2016 involving Resident #3. 2. Description of Incident. Resident #1: March 28, 2016 at 9:20 AM- During an off campus doctor's appointment, Transportation Driver #1 reported that Resident #1 fell while in his wheelchair from the back of the lift van to the ground. Certified Nursing Assistant (CNA) #1 was accompanying staff during the transport. Resident #1 was sent to the local emergency room with a small laceration to the back of his head. Resident #3: April 27, 2016 at 2:50 PM- En route to an off campus doctor's appointment, Transportation Driver #2 reported that Resident #3 slid out of the Geri-Chair that was used to transport Resident #3 onto the floor of the lift van. Injuries related to the fall included a fractured nose and a fractured left femur. Licensed Practical Nurse (LPN) #1 was the accompanying staff during the transport. 3. Measures Implemented: Resident #1: March 28, 2016 at 9:30 AM- Nursing Manager contacted Hospital Director to notify him of the Resident #1 incident. Hospital Director gave directive to refer the incident to Investigative Services and the Quality Assurance Department. Resident #3: April 27, 2016 at 3:00 PM- Nursing Home Administrator contacted Hospital Director to notify him of the Resident #3 incident. Hospital Director gave a directive to the Nursing Home Administrator to suspend all transportation of residents requiring a Geri-Chair until the cause of the accident has been determined and to contact the local non-emergency ambulance service for future transportation of those residents. 4. Resident #1: March 29, 2016 at 9:00 AM- Quality Assurance Department requested a plan of correction from the Public Safety Director in regards to the Resident #1 incident. The Public Safety Director's plan of correction included immediately retraining all transportation drivers on the proper operation of the lift-van. Resident #3: April 27, 2016 at 3:10 PM- The Nursing Home Administrator notified the Public Safety Director and the Nurse Manager of the directive and to inform their staff. The Public Safety Director notified the transportation Supervisors of the directive and to inform their staff. 5. Policy Revision: Resident #1: There were no policy revisions for this incident. Resident #3: April 28, 2016 at 10:30 AM- Public Safety Director submitted a revision of Policy 305-03 Transportation of Individual Receiving Services to Policy and Procedure committee Chair to include staff sitting in the back of the van with the resident to observe, monitor and assist the residents. On May 5, 2016 at 11:00 AM, Public Safety Director submitted a second revision of Policy 305-03 Transportation of Individual Receiving Services to Policy and Procedure Committee. Revisions included the replacement of wheelchairs and geri-chairs with vehicle approved transport chairs. Both revisions were approved for implementation. 6. Training/In-services: Resident #1: March 29, 2016 at 10:00 AM- Transportation Supervisor trained all transportation drivers on proper use of operation of lift van. Transportation drivers were not allowed to operate the lift van until trained. No transportation staff was allowed to report to work until trained of the above mentioned. Resident #3: April 28, 2016 at 11:00 AM- Nurse Manager trained nursing staff (RN, LPN and CNA) that effective immediately staff must sit in the back of the van with residents when accompanying residents to monitor, observe and assist the resident during transport. On May 5, 2016 at 4:00 PM, Nurse Educator trained staff (Transportation driver, RN, LPN, Physicians, CNAs, Social Workers, Psychology Staff, Recreations, Direct Care Trainee, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) on the first and second revision of Policy 305-03 Transportation of Individual Receiving Services. No resident will be transported in Geri-Chairs. Only Vehicle approved transport chairs will be utilized. No staff was allowed to report to work until trained of the above mentioned. 7. Audits: Resident #1: April 8, 2016 at 10:00 AM- Public Safety Director implemented a Lift Van Operation Checklist audit form in the plan of correction to include each transportation drivers receiving (5) monthly audits for 90 days. Audits began on April 11, 2016 with a 100% compliance rate. Resident #3: Nursing Home Administrator has conducted audits to ensure compliance with the suspension of Geri-Chair transport since April 27, 2016. There have been no Geri-Chairs transported since April 27, 2016. 8. Disciplinary Actions: Resident #1: March 28, 2016 at 10:00 AM- Transportation Driver #1 was referred to Human Resources for disciplinary actions. Resident #3: There will be no staff disciplinary actions taken for Resident #3 Incident. It was determined that it was a system failure due to the use of a Geri-Chair that was not authorized for vehicle transport. 9. Notification of State Agencies: Resident #1: March 28, 2016 at 4:35 PM- Mississippi Department of Health and Mississippi Attorney General Office were notified of incident involving Resident #1. Resident #3: April 28, 2016 at 8:47 AM- Mississippi Department of Health and Mississippi Attorney General Office were notified of incident involving Resident #3. 10.Quality Assurance: Resident #1 and Resident #3: April 28, 2016 at 10:00 AM- Nursing Home Administrator met with the Safety Committee to discuss and examine the Geri-Chair involved in the incident. The sub-committee Safety Committee members include: Medical Services Director/Physician, Director of Public Safety Division/Risk Manager/Safety Committee Chair, Nursing Home Administrator, Assistant Hospital Director, Physical Plan Director, Nurse Executive, Director of Nursing, Director of Accreditation, Maintenance Worker, RN Nurse Supervisor, Certified Nursing Assistant, and Nursing Home Administrator. The sub-committee supported the directive of suspending transport of residents in Geri-Chairs. It was recommended to purchase a vehicle approved transport chair. April 29, 2016 at 3:00 PM- Public Safety Director submitted a description of a vehicle approved transport chair to Business Services. A purchase requisition was submitted and approved on 5/4/16 for a vehicle approved transport chair. May 5, 2016 at 3:23 PM- Quality Assurance committee met to discuss the incident involving Resident #1 and Resident #3. The members of the QA Committee include: Nursing Home Administrator, Outcome Services Division Director, RN/Quality Assurance Nurse, Medical Services Director/Physician, Director of Nursing, RN/Nurse Educator, Certified Nursing Assistant Supervisor, Risk Manager/Director of Public Safety, RPW Nursing Home Administrator, Professional Development/Policy Management Director, RN Nurse Supervisor, LPN Nurse Educator, RN/Investigative Services. The QA Committee implemented the following changes: 1. Revision of Policy 305-03 Transportation of Individual Receiving Services. Wheelchairs and Geri-Chairs was deleted from the policy and replaced with vehicle approved transport chairs. 2. Revision of Lift Van Operation Checklist audit form. Wheelchairs and Geri-Chairs was deleted for the form and replaced with vehicle approved transport chairs. 3. Suspension of transporting residents until completion of training on the revision in Policy 305-03 Transportation of Individual Receiving Services. 4. Effective immediately on 5/5/16 at 3:30 PM, until completion of training on Policy 305-03 Transportation of Individual Receiving Services, the transportation of all resident was suspended. 5. Staff (Transportation Staff, RN, LPN, CNA, Physicians, Social Workers, Psychology Staff, Recreation, Direct Care Trainees, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) will not be able to work until trained. 11.Removal of Immediate Jeopardy: All Activities to remove the immediate jeopardy have been accomplished on 5/7/16 and the facility alleges that the removal of the immediate jeopardy effective as of 5/8/16. This Credible AoC was signed by the facility Administrator on 5/7/16 at 1:30 PM. On 5/9/16, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy: The acceptable Credible Allegation of Compliance was verified by staff interviews and record review of in-services on March 29, 2016 at 10:00 AM, the Transportation Supervisor trained all transportation drivers on proper use and operation of the lift van. On April 28, 2016 at 11:00 AM, the Nurse Manager trained the nursing staff (RNs, LPNs and CNAs) that staff must sit in the back of the van with residents when accompanying residents to monitor, observe and to assist the resident during transport. On May 5, 2016 at 4:00 PM, the Nurse Educator trained staff (Transportation driver, RN, LPN, Physicians, CNAs, Social Workers, Psychology Staff, Recreations, Direct Care Trainee, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) on the first and second revision of Policy 305-03, Transportation of Individual Receiving Services, and that no residents will be transported in Geri-Chairs and only Vehicle approved transport chairs will be utilized. All staff, across all disciplines were trained, except seven (7) that were off on medical leave or vacation but would not be allowed to report to work until trained. These interviews included RNs, LPNs, CNAs, Social Services Staff, Activities Staff, Health Information Staff, Admissions/Marketing Director, Dietary Staff, Housekeeping/Laundry Staff, Maintenance Staff, Business Office Staff, Director of Nursing, Transportation Drivers, Director of Public Safety and the Facility Administrator. The content of the in-services held on March 29, 2016 at 10:00 AM, April 28, 2016 at 11:00 AM and May 5, 2016 at 4:00 PM were verified during each interview. Six (6) RNs, eight (8)LPNs, twenty-one (21) CNAs, two (2) Social Services Staff, one (1) Activities Staff, two (2) Health Information Staff, one (1) Admissions/Marketing staff, one (1) Dietary Staff, seven (7) Housekeeping/Laundry Staff, three (3) Maintenance Staff, two (2) Business Office/Health Information Staff, Director of Nursing, three (3) Transportation Drivers verified being in-serviced on the facility's policy/procedures for transporting residents and that no resident will be transported in a Geri-Chair or Wheelchair only a vehicle approved transport chair, staff accompanying residents on transport are to sit in the back with the residents at all times. Three (3) Transportation Drivers verified they received an in-service on the facility's policy/procedure for proper use and operation of the lift van. Review of the Disciplinary Action for Transportation Driver #1 revealed Transportation Driver #1 was suspended from work and received a written reprimand for violation of safety rules dated 4/4/16. Review of the State Agency Complaint intake form revealed the facility reported the incident involving Resident #1 on 4/22/16 and Resident #3 on 4/28/16 and received facility investigative report on 5/5/16. Review of the Quality Assurance meeting dated 5/5/16 confirmed the meeting consisted of covering the incident involving Resident #1 and Resident #3. The QA Committee implemented the following changes: 1. Revision of Policy 305-03 Transportation of Individual Receiving Services. Wheelchairs and Geri-Chairs was deleted from the policy and replaced with vehicle approved transport chairs. 2. Revision of Lift Van Operation Checklist audit form. Wheelchairs and Geri-Chairs was deleted for the form and replaced with vehicle approved transport chairs. 3. The suspension of transporting residents until completion of training on the revision in Policy 305-03 Transportation of Individual Receiving Services. 4. Effective immediately on 5/5/16 at 3:30 PM, until completion of training on Policy 305-03 Transportation of Individual Receiving Services, the transportation of all residents was suspended. 5. Staff (Transportation Staff, RN, LPN, CNA, Physicians, Social Workers, Psychology Staff, Recreation, Direct Care Trainees, Administrative Staff, Maintenance, Clerical Staff, Housekeeping and Laundry Staff) will not be able to work until trained. Record review revealed the Lift Van Operation Checklist audits had 100% compliance, from 4/11/16 to 5/5/16 that was completed by the Transportation Supervisor. The QA committee recommended the purchase of a vehicle approved transport chair and supported the directive of suspending transport of residents in Geri-Chairs. Record review of a Purchase Order (PO) requisition for a transport approved chair that has been crash tested to meet the WC-19 standards for occupant transport, with the PO number of was issued on 5/4/16 after approval was obtained. The State Agency Surveyor reviewed the revised policies submitted by the Public Safety Director, Policy 305-03 Transportation of Individual Receiving Services to Policy and Procedure committee Chair to include staff sitting in the back of the van with the resident to observe, monitor and assist the residents. On May 5, 2016 at 11:00 AM, Public Safety Director submitted a second revision of Policy 305-03 Transportation of Individual Receiving Services to Policy and Procedure Committee. Revisions included the replacement of wheelchairs and geri-chairs with vehicle approved transport chairs. Both revisions were approved for implementation.

This REQUIREMENT is not met as evidenced by: Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure Resident #5's care plan was followed for pain management during wound care, for one of seven (1 of 7) resident care plans reviewed. Findings include: The facility's policy entitled, Interdisciplinary Care Plan, revised October 2012, indicated the facility would develop a written individualized care plan that meets the needs and choices of each resident as well as addresses theirs strengths, weaknesses and goals identified by the resident's assessment, reassessment, and results of diagnostic testing. The care plan will be reviewed quarterly, annually, or when the resident has a significant change to evaluate the care plan's effectiveness. The entire health record should be considered the, plan of care. Resident #5 Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/27/15, revealed the Brief Interview for Mental Status (BIMS) score was not done because Resident #5 was rarely or never understood. The cognitive skills for daily decision making was coded a three (3), which indicated severe impairment. Further review of the MDS's Active [DIAGNOSES REDACTED]. A review of the care plan updated 5/27/15, identified as a problem, Resident #5 required total assist with Activities of Daily Living (ADLs) related to (R/T) [DIAGNOSES REDACTED], Joint Contractures, and Chronic Pain. The approaches listed included, if the resident yells out when touched or repositioned during care ask her if she is in pain, and notify the nurse for further evaluation. During a Pressure Ulcer (PU) care observation on 8/6/15 at 11:20 AM, Licensed Practical Nurse (LPN) #3 removed the old pressure wound dressing, wiped the wound center with a wound cleanser on four by four (4X4) gauze pads. LPN #3 asked Resident #5 at this time if it hurt, Resident #5 replied yeah. LPN #3 continued the pressure wound care by patting the area dry with dry 4X4s. LPN #3 washed her hands, and changed gloves. Resident #5 continued to moan during the treatment, but would state she was, OK. LPN #3 applied the [MEDICATION NAME] to the wound bed, several 4X4 gauze pads, and kerlix. Resident #5 was yelling out in pain as LPN #3 continued to tape the dressing in place. LPN #3 did not thoroughly assess Resident #5's complaint of pain/hurting, or moaning during the pressure wound care. An interview on 8/6/15 at 11:50 AM, revealed LPN #3 stated, She hurts during the treatment but once we are finished, she is fine. LPN #3 stated Resident #5 had received a [MEDICATION NAME] 7.5mg (seven and five tenths milligrams)/325mg tablet at 8:00 AM prior to the wound care. This was three (3) hours and twenty minutes prior to the pressure wound care. Review of Resident #5's August 2015 physician's orders [REDACTED]. tablet one (1) per PEG (Percutaneous Endoscopic Gastrostomy) tube at 8 AM and 8 PM d/t Chronic Pain. Use the Numeric Pain Scale one (1) to 10. Document scale prior to administering. In an interview with the Director of Nursing (DON)on 8/6/15 at 6:35 PM, she stated, The staff uses the Care Guides and the ADL books as well as the Care Plan to see what care is required for each resident. The DON also stated, The Care Plan is individualized for each resident. The interview with LPN #3 on 8/6/15 at 11:50AM revealed that LPN #3 stated that the care plans, and blue charts were located in the chart room, so she was aware of where the care plans could be found. Review of the Face Sheet revealed the facility admitted Resident #5 on 4/1/10, with the [DIAGNOSES REDACTED].

Based on observation, staff interview, and record review, the facility failed to assess and manage pain during a Pressure Ulcer (PU) dressing change for one (1) of four (4) care observations. (Resident #5) Findings include: Review of the facility's policy entitled, Wound Care, revised October 2013, revealed the purpose of this policy was to establish procedures to promote healing of wounds. Further review of the policy revealed it did not address pain assessment/management related to wound care. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 5/27/15, revealed the Brief Interview for Mental Status (BIMS) score was not done because Resident #5 was rarely, or never understood. The cognitive skills for daily decision making was coded a three (3), which indicated severe impairment. Further review of the MDS revealed Resident #5 had Chronic Pain, a Stage III (3) or IV (4) Pressure Ulcer, and was at risk for the development of Pressure Ulcers. During a Pressure Ulcer (PU) care observation on 8/6/15 at 11:20 AM, Licensed Practical Nurse (LPN) #3, assisted by LPN #4, failed to provide additional measures to assure comfort and pain relief when Resident #5 cried out in pain/moaned during the wound care. Resident #5 moaned, and cried out in pain three (3) times during this observation with no pain assessment or reduction interventions attempted. Licensed Practical Nurse (LPN) #3 removed the old pressure wound dressing, wiped the wound center with a wound cleanser on four by four (4X4) gauze pads. LPN #3 asked Resident #5 at this time if it hurt, Resident #5 replied yeah. LPN #3 continued the pressure wound care by patting the area dry with dry 4X4s. LPN #3 washed her hands, and changed gloves. Resident #5 continued to moan during the treatment, but would state she was, OK. LPN #3 applied the [MEDICATION NAME] to the wound bed, several 4X4 gauze pads, and kerlix. Resident #5 was yelling out in pain as LPN #3 continued to tape the dressing in place. LPN #3 did not thoroughly assess Resident #5's complaint of pain/hurting, or moaning during the pressure wound care. In an interview on 8/6/15 at 11:50 AM, LPN #3 stated, Resident #5 received [MEDICATION NAME] 7.5 (seven and five tenths/325 milligrams (mg) at 8:00 AM, and 10:00 PM. LPN #3 reported Resident #5 did receive the medication at 8:00 AM, prior to the dressing change at 11:20 AM. LPN #3 stated, While doing treatment . she hurts but once we finish she's fine. When asked, When was the last in-service on wound care that you attended? LPN #3 stated, I don't think I have had one. Review of Resident #5's August 2015 physician's orders [REDACTED]. tablet one (1) per PEG (Percutaneous Endoscopic Gastrostomy) tube at 8 AM and 8 PM d/t Chronic Pain. Use the Numeric Pain Scale one (1) to 10. Document scale prior to administering. In an interview with the Director of Nursing (DON)on 8/6/15 at 12:05 PM, she confirmed the nurses were suppose to ask the residents if they need anything for pain, and give pain medication 30 minutes before the procedure. Review of the Face Sheet revealed the facility admitted Resident #5 on 4/1/10, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 5/27/15, revealed the Brief Interview for Mental Status (BIMS) score was not done because Resident #5 was rarely, or never understood. The cognitive skills for daily decision making was coded a three (3), which indicated severe impairment. Further review of the MDS revealed Resident #5 had Chronic Pain, a Stage III (3) or IV (4) Pressure Ulcer, and was at risk for the development of Pressure Ulcers.