Every finding on record at Reginald P White Nursing Facility

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from neglect when two (2) staff members completed a resident transfer with a mechanical lift without using the required four (4) staff members for resident safety, which resulted in the resident falling backward for one (1) of three (3) sampled residents. Resident #1. Findings include: A review of the facility's policy Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, And/or Misappropriation of Funds/Property To Individuals Receiving Services/Residents, revised January 2024, revealed, .It is the policy.to affirm that all Individuals Receiving Services (IRS)/Residents have a right to be free from.neglect.Definitions.Neglect: The failure to supply an IRS with food, shelter, clothing, or other services necessary to maintain physical and mental health. A record review of the Face Sheet revealed the facility admitted Resident #1 on 7/31/23 with diagnoses including Parkinson's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/25/25 revealed Resident#1 had a Brief Interview for Mental Status (BIMS) summary score of 09, which indicated her cognition was moderately impaired. A record review of the Investigative Summary Report revealed the date of the incident was 8/30/25 and the Type of incident was listed as Staff violation of care plan/physician orders causing accident. A Description of the Incident indicated that on 8/30/25 at approximately 10:27 AM, Resident #1 sustained a fall in her bedroom. At the time of the fall Resident #1 was being transferred from the bed to a transport chair. Once Resident #1 was seated into the transport chair it fell backwards landing onto the floor. Resident #1 complained of her head hurting with no visible injuries noted. The resident was transferred to local emergency room for further medical evaluation. Investigation into this accident/incident showed that at the time of the event Resident #1 was being transferred using a Hoyer lift from her bed to a transport chair by two (2) CNAs. Resident #1 was care planned for a four person assist (three CNAs and one nurse). CNAs #1 and #2 were the only two employees conducting the bed to chair transfer, which violates the care plan/doctor's orders. They were both placed on administrative leave, pending investigation. A record review of CNA #1 signed statement dated 8/30/25 revealed she was aware of the 4 people assist for Resident #1 and stated We have been short of staff and only 2 people has been assisting.A record review of CNA #2 signed statement dated 8/30/25 revealed, .knew resident at the time was a 4 person assist, but when I went to a meeting, prior till this date, we all was told 2 person. was thinking 2 person assist from that meeting.A record review of the facility's .Hoyer Lift care plan failure document revealed the facility had implemented corrective actions. On 9/2/25 and 9/5/25, the facility held a Quality Assurance (QA) committee meeting to discuss the incident. Training on Neglect and review of the manufacturer's instruction mechanical lift and transport chair was conducted immediately. Additional training was conducted by the Attorney General related to Resident Rights and Suspicion of Abuse, Neglect was conducted from 9/23/25 to 9/24/25. Disciplinary actions included both CNAs placed on administrative leave and terminated from employment. On 10/21/25 at 12:30 PM, during an interview with the Director of Nursing (DON), she confirmed that staff failed to provide the necessary care and supervision to ensure Resident #1's safety during a transfer. The DON stated that two Certified Nurse Assistants (CNAs) attempted to transfer Resident #1 using a mechanical lift without obtaining the additional assistance required to safely complete the procedure. She acknowledged that the resident's condition required more staff support due to physical limitations and risk for instability, and performing the transfer with only two CNAs did not meet the resident's needs and placed her at risk for injury. The DON stated that the incident may have been prevented if staff had followed established facility expectations for safe transfers. She emphasized that it is the facility's responsibility to ensure that staff provide necessary care and services to prevent neglect and protect resident safety.On 10/21/25 at 1:00 PM, during an interview with the Administrator, he confirmed that the facility maintained written policies addressing resident safety during transfers, proper use of mechanical lifts and transport chairs, and adherence to physician orders and care plans. The Administrator stated that all staff had been trained, and competencies validated on these procedures. He acknowledged that, despite adequate staffing and clear instructions requiring a four-person assist (three CNAs and one nurse) for Resident #1's transfers, two CNAs failed to obtain the additional assistance required to safely complete the transfer. The Administrator stated that this failure to provide necessary care and services placed the resident at risk for injury and constituted neglect, as staff did not ensure the resident's safety during the transfer. He verified that the facility immediately suspended and later terminated the two CNAs for failing to follow safety policies, initiated in-services for all nursing staff on proper mechanical lift use and resident supervision, and convened emergency Quality Assurance and Performance Improvement (QAPI) meetings on 9/2/25 and 9/5/25 to review the incident, reinforce policies, and prevent recurrence. The Administrator confirmed that the facility reported the incident to the State Agency and the Attorney General's Office within the required five (5)-day timeframe.On 10/21/25 at 1:30 PM, during a phone interview with CNA #1, she confirmed that she was asked by CNA #2 to assist in transferring Resident #1 into her transfer chair. CNA #1 revealed that following the transfer with the mechanical lift, the resident was seated upright in the chair when the chair flipped backward. She further reported that Resident #1 was normally transferred with three (3) CNAs and a nurse present; however, the CNA #2 told her that the protocol had recently been changed to only two (2) CNAs.Based on the facility's implementation of corrective actions on 9/5/25, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) and corrected as of 9/5/25, prior to the SA's first entrance on 10/20/25. Validation:The SA validated on 10/22/25 through interview and record review, that all corrective actions had been implemented as of 9/5/25 and the facility was in compliance, prior to the SA's entrance on 10/20/25.

Based on interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan interventions related to transferring a resident with a Hoyer (type of mechanical lift) for one (1) of three (3) residents reviewed for care plan implementation. (Resident #1)Findings include:A review of the facility's policy Interdisciplinary Care Plan Team, dated August 2024, revealed, .The purpose of the team is to define and coordinate the treatment for each resident. A record review of the Face Sheet revealed the facility admitted Resident #1 on 7/31/23 with diagnoses including Parkinson's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/25/25 revealed Resident#1 had a Brief Interview for Mental Status (BIMS) summary score of 09, which indicated her cognition was moderately impaired. A record review of the Physician Order Report revealed Resident #1 had an order, dated 7/3/25 for Transfer using Hoyer lift with 4 (four) person asst (assistance) to include nurse and 3 CNA's.A record review of the Care Plan revealed Resident #1 had a Problem of Potential for Falls and an Approach, start date 1/28/2025, for Transferred using Hoyer Lift with 4 (Four) Person Assist with Nurse and 3 CNAs.A record review of the Investigative Summary Report revealed the date of the incident was 8/30/25 and the Type of incident was listed as Staff violation of care plan/physician orders causing accident. A Description of the Incident indicated that on 8/30/25 at approximately 10:27 AM, Resident #1 sustained a fall in her bedroom. At the time of the fall Resident #1 was being transferred from the bed to a transport chair. Once Resident #1 was seated into the transport chair it fell backwards landing onto the floor. Resident #1 complained of her head hurting with no visible injuries noted. The resident was transferred to local emergency room for further medical evaluation. Investigation into this accident/incident showed that at the time of the event Resident #1 was being transferred using a Hoyer lift from her bed to a transport chair by two (2) CNAs. Resident #1 was care planned for a four person assist (three CNAs and one nurse). CNAs #1 and #2 were the only two employees conducting the bed to chair transfer, which violates the care plan/doctor's orders. They were both placed on administrative leave, pending investigation. A record review of CNA #1 signed statement dated 8/30/25 revealed she was aware of the 4 people assist for Resident #1 and stated, We have been short of staff and only 2 people has been assisting.A record review of CNA #2 signed statement dated 8/30/25 revealed, .knew resident at the time was a 4 person assist, but when I went to a meeting, prior till this date, we all was told 2 person. was thinking 2 person assist from that meeting.A record review of the facility's .Hoyer Lift care plan failure document revealed the facility had implemented corrective actions. On 9/2/25 and 9/5/25, the facility held a Quality Assurance (QA) committee meeting to discuss the incident. Training on following the care plan guide was conducted immediately and disciplinary actions included both CNAs placed on administrative leave and terminated from employment. On 10/21/25 at 11:30 AM, an interview with Registered Nurse/MDS #1 revealed that care plans are individualized based on each resident's assessment, needs, and functional abilities. She revealed that the two CNAs involved in Resident #1's transfer did not follow the care plan, which required a four-person assist (three CNAs and one nurse) when using the Hoyer lift. She emphasized that it is her expectation that all licensed nurses and CNA's review and follow the resident's current care plan to ensure consistent, safe care and to prevent avoidable accidents.On 10/21/25 at 12:30 PM, during an interview with the Director of Nursing (DON), she revealed that staff did not follow the resident's comprehensive care plan when performing Resident #1's transfer using only two (2) CNA's, instead of the required three (3) CNA's and one (1) licensed nurse. The DON confirmed that the accident may have been prevented if the care plan interventions had been followed as written. She emphasized that it is the facility's expectation that all staff adhere to each resident's individualized care plan to ensure safety of the residentsOn 10/21/25 at 1:30 PM, a phone interview with CNA #1 confirmed that she was asked by CNA #2 to assist in transferring Resident #1 into her transfer chair. CNA #1 revealed that following the transfer with the Hoyer lift, the resident was seated upright in the chair when the chair flipped backward. She further reported that Resident #1 was normally transferred with three (3) CNAs and a nurse present; however, the CNA #2 told her that the protocol had recently been changed to two (2) CNAs.Based on the facility's implementation of corrective actions on 9/5/25, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) and the deficiency was corrected as of 9/5/25, prior to the SA's first entrance on 10/20/25. Validation:The SA validated on 10/22/25 through interview and record review, that all corrective actions had been implemented as of 9/5/25, prior to the SA's entrance on 10/20/25.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to maintain infection control practices during an annual recertification survey on 1/11/2024 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of three (3) deficiencies cited. (F880) Findings Include: A review of the facility's Quality Assurance document (undated) revealed, .The Outcome Services Division will .Periodically assess information based on established indicators, taking action to solve problems and pursue opportunities to improve quality . Record review of the Provider History Profile revealed the facility received a citation for F880-Infection Prevention & Control for the survey date of 1/11/2024. Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 1/11/2024, revealed the facility received a citation for F880, .Based on observation, staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection . during wound care for one (1) of five (5) wounds observed . During the current recertification survey, the facility failed to ensure staff followed appropriate infection prevention and control practices for two (2) of 18 sampled residents, Resident #13 and Resident #45. Specifically, the facility failed to ensure Registered Nurse (RN) #2 performed hand hygiene and donned appropriate personal protective equipment (PPE) while administering medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube for Resident #13 who required enhanced barrier precautions (EBP) and failed to ensure Licensed Practical Nurse (LPN) # 1 followed EBP and glove-changing protocols during wound care for Resident #45. On 05/29/25 at 2:43 PM, in an interview, the Nursing Home Administrator (NHA) confirmed he was aware that during the prior annual survey, a Licensed Practical Nurse (LPN) was cited for failure to perform hand hygiene during wound care. He stated that since the prior citation, nurses had been retrained, and QAPI had focused on correcting the issue. He stated that QAPI meets monthly and that after three months of focused wound policy correction and achieving what they considered 100% compliance, the QAPI committee shifted focus to other issues. He further stated that follow-up may now occur only one to two times per year. He acknowledged that recent in-services focused on infection control had been conducted in the past few months.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff followed appropriate infection prevention and control practices for two (2) of 18 sampled residents, Resident #13 and Resident #45. Specifically, the facility failed to ensure Registered Nurse (RN) #2 performed hand hygiene and donned appropriate personal protective equipment (PPE) while administering medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube for Resident #13 who required enhanced barrier precautions (EBP) and failed to ensure Licensed Practical Nurse (LPN) # 1 followed EBP and glove-changing protocols during wound care for Resident #45. The scope/severity for F880 was increased to E due to previous citation on the annual recertification survey on 1/11/24. Findings included: A review of the facility's Enhanced Barrier Precautions Protocol (undated), revealed, 1. Enhanced Barrier Precautions (EBP) are required for certain resident categories .3. For residents for whom EBP is indicated, EBP is employed when performing the following high-contact resident care activities .Device care or use .feeding tube .Wound care: any skin opening requiring a dressing . A review of the facility's policy, Hand Hygiene, revised 9/23, revealed: It is the policy .that employees will use proper hand hygiene techniques to prevent the spread of infectious diseases . Procedure .C. Employees must always wash hands .(4) Before performing invasive procedures .(7) Before and after touching wounds. (8) After removing gloves . Resident #13 On 5/29/25 at 9:23 AM, during an observation of a medication pass for Resident #13, RN #2 administered medications via a PEG tube. RN #2 wiped down the bedside table with an antibacterial wipe while wearing gloves, then removed her gloves without performing hand hygiene. She applied a new set of gloves, placed a barrier on the bedside table, removed her gloves again, and applied a second clean pair without hand hygiene. She failed to don a gown at any point during the procedure, despite the resident requiring EBP. On 5/29/25 at 10:40 AM, during an interview, RN #2 stated she should have performed hand hygiene initially and between glove changes. She also stated she should have worn a gown to protect the resident from potential contamination. She acknowledged these failures put the resident at risk for infection and noted she had received prior training on hand hygiene and EBP but forgot to follow protocol. On 5/29/25 at 11:05 AM, during an interview, RN #3, the Infection Preventionist stated nurses are expected to perform hand hygiene before starting care and between glove changes. She stated that gowns should be worn before initiating care under EBP protocols and confirmed that failure to do so could lead to infection. She stated staff received recent training on hand hygiene and EBP. On 5/29/25 at 1:40 PM, during an interview, the Acting Director of Nursing (DON) confirmed that RN #2 should have worn a gown before starting care and performed hand hygiene between glove changes. She stated the nurse could have used hand sanitizer or washed her hands, and that failing to do so risked transmitting germs or bacteria to the resident. A record review of the Face Sheet revealed the facility admitted Resident #13 on 8/5/24. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/2/25 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated her cognition was moderately impaired. A record review of the Physician Order Report for 5/1/25 through 5/31/25 revealed Resident #13 had diagnoses including Gastrostomy status and had medications required to be administered via a PEG tube. Resident #45 On 5/28/25 at 12:58 PM, LPN #1 was observed performing wound care for Resident #45. Prior to initiating care, she failed to don a gown, despite the resident being on EBP. During the procedure, she cleansed a dirty wound bed and then applied a new dressing without removing or changing her gloves, thereby applying the clean dressing with contaminated gloves. On 5/28/25 at 1:35 PM, during an interview, LPN #1 acknowledged that she should have worn a gown and changed gloves during the wound care procedure to prevent infection. She confirmed that the resident was on EBP, and her actions did not follow protocol. On 5/28/25 at 1:38 PM, during an interview, the DON confirmed that LPN #1 should have worn a gown before entering the room and should have changed gloves during the procedure. She stated gowns were available in the room and that failure to change gloves risked spreading infection. A record review of the Nurse Competency Skill Assessment for Wound Care revealed that gloves should be removed, and clean gloves donned four times during wound care-specifically after cleansing a dirty wound and before applying a new dressing, in accordance with physician orders and manufacturer instructions. On 5/29/25 at 1:08 PM, during an interview, the facility's Infection Preventionist (IP Nurse) stated that LPN #1 should have worn a gown and changed gloves prior to applying the new dressing. She stated failure to do so contaminated the dressing and placed the resident at risk of infection. A record review of the Face Sheet revealed the facility admitted Resident #45 on 12/21/22. A record review of the Physician Order Report revealed Resident #45 had diagnoses including Venous Insufficiency and had a treatment with a start date of 4/25/25 to .Venous wound left anterior superior lower leg: Clean with normal saline, pat dry, apply Xeroform gauze and cover with dry dressing daily and PRN (as needed) . A record review of the Quarterly MDS with an ARD of 4/11/25 revealed Resident #45 had a BIMS score of three (3), which indicated his cognition was severely impaired.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure nursing services were provided in accordance with professional standards of practice by not verifying Percutaneous Endoscopic Gastrostomy (PEG) placement prior to administering medications for one (1) of four (4) residents observed for medication administration. Resident #13. Findings included: A review of the facility's policy titled Tube Enteral Nutrition, revised 10/24, revealed, The purpose of this protocol is to establish general guidelines for the use of tube enteral feedings for residents/Individuals Receiving Services (IRS) with a functioning Gastrointestinal Tract . On 5/29/25 at 9:23 AM, during an observation of medication administration via PEG tube, Registered Nurse (RN) #2 administered MiraLAX, potassium chloride, and ibuprofen to Resident #13 without verifying PEG tube placement prior to administration. On 5/29/25 at 10:40 AM, during an interview, RN #2 confirmed she had not verified PEG tube placement before administering medications. RN #2 acknowledged that placement verification is necessary to ensure the tube is in the correct position and stated that medications delivered into the body cavity could lead to complications. On 5/29/25 at 1:40 PM, during an interview with the acting Director of Nursing (DON), she stated that RN #2 should have verified PEG tube placement prior to medication administration. The DON confirmed that failure to verify placement could result in complications A record review of the Face Sheet revealed the facility admitted Resident #13 on 8/5/24. A record review of the Physician Order Report revealed Resident #13 had diagnoses including Gastrostomy Status. Further review revealed Resident #13 had Physician Orders for Pro-Stat via PEG tube two (2) times daily (start date of 8/15/24); Potassium Chloride liquid 20 milliequivalent (mEq)/15 milliliter (mL), 15 mL via PEG tube daily (start date of 1/23/25); Ibuprofen suspension 100 milligrams (mg)/5 mL, 30 mL per tube; oral tube twice daily (start date of 9/18/24); MiraLAX powder 17 grams per PEG tube (start date of 8/9/24). A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/2/25 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident's cognition was moderately impaired.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical abuse by a staff member for one (1) of three (3) sampled residents. Resident #1. Resident #1 was physically abused on 12/31/24 when a Certified Nurse Assistant (CNA) #1 dragged him by his shirt, the collar, and the shoulders of his jacket up the hallway into Resident #1's room. One nurse observed the abuse and failed to intervene, allowing the abuse to escalate. The facility's failure to protect Resident #1 from abuse placed this resident and all residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy and Substandard Quality of Care (SQC) that began on 12/31/24. The State Agency (SA) notified the Administrator of the IJ and SQC on 2/11/25 at 4:45 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 1/7/25, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 1/8/25. Findings include: A review of the facility policy titled Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, And/or Misappropriation of Funds/Property To Individuals Receiving Services/Residents, revised January 2024, revealed, .It is the policy .to affirm that all Individuals Receiving Services (IRS)/Residents have a right to be free from abuse .Definitions .Abuse: The willful infliction of physical pain, injury, or mental anguish, unreasonable confinement or the willful deprivation of services necessary to maintain physical and mental health .Mental Abuse: includes .humiliation, harassment .Prevention .(4) .will review, correct, and intervene in situations in which allegations of abuse, neglect .have potentially occurred .D. Reporting: (1) All employees .will immediately report any of the following (a) Witness of or discovery of any situation in which suspicion exits that an IRS/Resident has been the victim of abuse . A record review of the Investigative Summary Report, dated 1/7/25, revealed that on 12/31/24 at 2:21 PM, Resident #1 was dragged on the floor by CNA #1. The resident was assessed on 1/3/25 when the allegation was submitted, and the Director of Nurses (DON) was notified. It was reported on 1/3/25 that on 12/31/24, CNA #1 dragged Resident #1 on the floor by the neck of his shirt to his room because the resident positioned himself on the floor in the hallway near the nurse's station. The resident was observed lying on the floor, hitting his head, and refusing to keep his protective helmet on. The investigation into the allegation yielded evidence that CNA #1 did drag the resident by the neck and shoulder sections of his jacket up the hallway into his room. Staff were placed on administrative leave pending the investigation and following the investigation, CNA #1 and License Practical Nurse (LPN) #1 were terminated on 1/7/25. A record review of LPN #1's written statement, dated 1/6/25, revealed that on 12/31/24 between 2:00 PM and 2:30 PM, Resident #1 was banging his head against the wall. CNA #1 proceeded to grab the resident by his neck and sweatshirt and drag him to his room. She felt like she was choking him, and she felt like this was abuse. She reported to the security officer and attempted to notify her DON, but she was not in her office. On 2/10/25 at 2:00 PM, during an observation and interview, Resident #1 was lying in his bed and sat up to speak during the interview. He confirmed that he remembered the CNA who dragged him down the hall. He stated that she did not hurt him but commented that she didn't have to drag him like an old rag. Resident #1 explained that he was embarrassed by the CNA's actions. He reported that he often hits his head on the wall or the floor because he normally wants something and that is his way of getting attention from the staff, but on this day (12/31/24), he was dragged to his room by the CNA. On 2/10/25 at 2:35 PM, in an interview with the Campus Safety Officer, he confirmed he was working on 12/31/24, but stated he did not witness the event. He explained that an LPN approached him on 12/31/24 and asked him generalized questions about physical abuse, but she did not inform him of the incident that had occurred. He advised her to inform her immediate supervisor if she had questions on the definition of physical abuse. He reported he was not aware of the incident until the investigation began on 1/3/25. On 2/10/25 at 2:43 PM, during an interview with the Housekeeper, he confirmed that he witnessed Resident #1 being pulled by his clothing down the hall approximately 20 feet by a staff member. He stated he did not report the episode to his manager because he assumed the other staff would have reported it. Still, he was placed on administrative leave following the episode and attended many in-services on reporting following the episode. On 2/10/25 at 3:00 PM, during an observation of the surveillance video with the Administrator present, on 12/31/24 at 2:07 PM, CNA #1 was observed dragging/pulling Resident #1 by his arm/sleeve of his clothes, right side, approximately 16 feet to his room, and LPN #1 was observed walking beside the resident and the CNA. On 2/11/25 at 12:01 PM, during an interview with Registered Nurse (RN) #1, she confirmed that on 1/3/25, LPN #1 informed her that CNA #1 pulled Resident #1 down the hallway on the floor by his clothes because he was banging his head on the floor. LPN #1 stated that she attempted to re-direct him and place his helmet on, but he refused the helmet. LPN #1 revealed she attempted to notify security and the DON of the incident, but the DON wasn't available, so she didn't report it until her next shift on 1/3/25. RN #1 confirmed that the facility's policy is to report any abuse to a supervisor, DON, or Administrator. RN #1 stated that LPN #1 and CNA #1 did not treat Resident #1 with respect or dignity. On 2/11/25 at 12:30 PM, during an interview with CNA #2, she confirmed Resident #1 was her assigned resident on 12/31/24. She revealed that she witnessed CNA #1 drag the resident down the hallway but stated that she did not have time to intervene. She reported the event was over in just a few seconds. LPN #1 advised her that she was going to report the episode to security campus, so CNA #2 did not report the episode to any supervisor. On 2/11/25 at 1:00 PM, during a phone interview with CNA #1, she confirmed that she dragged Resident #1 down the hallway by his clothing. She said that Resident #1 was not her assigned resident, but he was sitting on the floor between two doors, and it was difficult for residents to get through the doorways. CNA #1 explained Resident #1 had had this behavior in the past to get attention, so she grabbed his clothes and pulled him about 20 feet to his room. She was not trying to do anything intentional to hurt him and she was not being vindictive, but he was hitting his head on the floor and the wall. CNA #1 confirmed that Resident #1 was not her assigned resident and she did not attempt to redirect him, nor offer him food or water. She explained that she just responded, and she did not think of the outcome. CNA #1 expressed remorse and commented that she has been very upset since the incident. In an interview with the Administrator on 2/11/25 at 3:40 PM, he confirmed that upon reviewing the video surveillance, CNA #1 dragged Resident #1 by his shirt/jacket to his room. He stated that this incident was a form of physical abuse and that LPN #1, who was present, should have intervened to stop the situation. During an interview with the DON on 2/11/25 at 4:00 PM, confirmed that following a review of the video surveillance, CNA #1 did drag Resident #1 on the floor by his clothing down the hall and placed him in his room. A record review of the Face Sheet, revealed the facility admitted Resident #1 on 8/7/24 with current diagnoses including Epilepsy, Bipolar Disorder, and Mild Intellectual Disabilities. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/5/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated his cognition was moderately impaired. Further review revealed his vision was severely impaired. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 2/10/25: The Quality Assurance (Quality Assurance) Committee held an Emergency QA Meeting on 1/7/2025. The Quality Assurance Committee discussed the description of the incident. The QA committee discussed and approved training that was provided beginning on 1/3/25 at the beginning of the shift to all staff on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, and misappropriation of funds/Property to Individuals Receiving Services/Residents and Resident # 1 behavior Intervention protocol. The additional will be monitored per staff for continued effectiveness as follows: Abuse/Neglect Policy & Adherence to Care Plan. Quality of correction will also be monitored by observing interventions and interactions with patients 5 (five) days a week for 8 (eight) weeks by Nurse Manager and four Nurse Supervisor, beginning on 1/21/25. Findings will be reported to QAPI (Quality Assurance Performance Improvement), beginning 2/13/25 times two months. On 1/3/25, all supervisors began training all the oncoming staff before the start of their shift on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, or Misappropriation of Funds/Property to Individuals Receiving Services/Residents, and Resident #1 Behavioral Intervention Protocol. No employee was allowed to work until there was in-service. On 1/3/2025 CNA #1 and License Practical Nurse (LPN)#1 were placed on administrative leave pending completion of the investigation. LPN #1 was terminated from employment on 1/7/25 for observing physical abuse and failing to report it in a timely manner. CNA #1 was terminated from employment effective 1/7/25 for physically abusing Resident #1. The Investigator notified the State Agency by telephone on 1/3/25, the Attorney General's Office in writing of the incident on 1/3/25. Supervisors began In-servicing all employees on 1/3/25 prior to the beginning their shift. The in-services were completed on 1/7/25. The facility alleges all corrective actions were completed on 1/7/25 and the IJ removed on 1/8/25 prior to the State Agency's entrance on 2/10/25. Validation: The SA validated on 2/12/25, through interview and record review, that all corrective actions had been implemented as of 1/7/25, and the facility was in compliance as of 1/8/25, prior to the SA's entrance on 2/10/25.

Based on observation, interviews, record review, and facility policy review, the facility failed to implement its abuse policy, allowing an abusive act to occur without staff intervening or prompt reporting for one (1) of three (3) sampled residents. Resident #1. Resident #1 was physically abused on 12/31/24 when Certified Nurse Assistant (CNA) #1 dragged him by his shirt, the collar, and the shoulders of his jacket up the hallway into Resident #1 room. One nurse observed the abuse and failed to intervene, allowing the abuse to escalate. The facility's failure to implement abuse policies and protect Resident #1 from physical abuse and the facility's failure to intervene placed this resident and all residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy and Substandard Quality of Care (SQC). The State Agency (SA) notified the Administrator of the IJ and SQC on 2/11/25 at 4:45 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 1/7/25, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 1/8/25. Findings include: A review of the facility policy titled Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, And/or Misappropriation of Funds/Property To Individuals Receiving Services/Residents, revised January 2024, revealed, .It is the policy .to affirm that all Individuals Receiving Services (IRS)/Residents have a right to be free from abuse .Definitions .Abuse: The willful infliction of physical pain, injury, or mental anguish, unreasonable confinement or the willful deprivation of services necessary to maintain physical and mental health .Mental Abuse: includes .humiliation, harassment .Prevention .(4) .will review, correct, and intervene in situations in which allegations of abuse, neglect .have potentially occurred .D. Reporting: (1) All employees .will immediately report any of the following (a) Witness of or discovery of any situation in which suspicion exits that an IRS/Resident has been the victim of abuse . A record review of the Investigative Summary Report, dated 1/7/25, revealed that on 12/31/24 at 2:21 PM, Resident #1 was dragged on the floor by CNA #1. The resident was assessed on 1/3/25 when the allegation was submitted, and the Director of Nurses (DON) was notified. It was reported on 1/3/25 that on 12/31/24, CNA #1 dragged Resident #1 on the floor by the neck of his shirt to his room because the resident positioned himself on the floor in the hallway near the nurse's station. The resident was observed lying on the floor, hitting his head, and refusing to keep his protective helmet on. The investigation into the allegation yielded evidence that CNA #1 did drag the resident by the neck and shoulder sections of his jacket up the hallway into his room. Staff were placed on administrative leave pending the investigation and following the investigation, CNA #1 and License Practical Nurse (LPN) #1 were terminated on 1/7/25. A record review of LPN #1's written statement, dated 1/6/25, revealed that on 12/31/24 between 2:00 PM and 2:30 PM, Resident #1 was banging his head against the wall. CNA #1 proceeded to grab the resident by his neck and sweatshirt and drag him to his room. She felt like she was choking him, and she felt like this was abuse. She reported to the security officer and attempted to notify the Director of Nursing (DON), but she was not in her office. During an observation and interview, on 2/10/25 at 2:00 PM, Resident #1 was lying in his bed. He confirmed that a CNA dragged him down the hall. He stated that it did not hurt but commented that she didn't have to drag him like an old rag. Resident #1 explained that he was embarrassed by the CNA's actions. He reported that he often hits his head on the wall or the floor because he normally wants something and that is his way of getting attention from the staff, but on this day (12/31/24), he was dragged to his room by the CNA. During an interview on 2/10/25 at 2:35 PM, the Campus Safety Officer, confirmed he was working on 12/31/24, but stated he did not witness the event. He explained that an LPN approached him on 12/31/24 and asked him generalized questions about physical abuse, but she did not inform him of the incident that had occurred. He advised her to inform her immediate supervisor if she had questions on the definition of physical abuse. He reported he was not aware of the incident until the investigation began on 1/3/25. During an interview on 2/10/25 at 2:43 PM, the Housekeeper confirmed that he witnessed Resident #1 being pulled by his clothing down the hall by a staff member. He stated he did not stop the situation because he felt it was not his place because there was a CNA and LPN present during the situation. During an observation of the video surveillance with the Administrator on 2/10/25 at 3:00 PM, on 12/31/24 at 2:07 PM, CNA #1 was observed dragging/pulling Resident #1 by his arm/sleeve of his clothes, right side, approximately 16 feet to his room, and LPN #1 was observed walking beside the resident and CNA. During an interview on 2/11/25 at 12:30 PM, CNA #2 confirmed Resident #1 was her assigned resident on 12/31/24. She revealed that she witnessed CNA #1 drag the resident down the hallway but stated that she did not have time to intervene. She reported the event was over in just a few seconds. LPN #1 advised CNA #2 that she was going to report the episode to security campus, so CNA #2 did not report the episode to any supervisor. During a phone interview on 2/11/25 at 1:00 PM, CNA #1 confirmed that she dragged Resident #1 down the hallway by his clothing. She said that Resident #1 was not her assigned resident, but he was sitting on the floor between two doors, and it was difficult for residents to get through the doorways. CNA #1 explained Resident #1 had this behavior in the past to get attention, so she grabbed his clothes and pulled him about 20 feet to his room. She was not trying to do anything intentional to hurt him and she was not being vindictive, but he was hitting his head on the floor and the wall. CNA #1 confirmed that Resident #1 was not her assigned resident and she did not attempt to redirect him, nor offer him food or water. She explained that she just responded, and she did not think of the outcome. CNA #1 expressed remorse and commented that she has been very upset since the incident. During an interview with the Administrator on 2/11/25 at 3:40 PM, he confirmed that upon reviewing the video surveillance, CNA #1 dragged Resident #1 by his shirt/jacket to his room. He stated that this incident was a form of physical abuse and that LPN #1, who was present, should have intervened to stop the situation, they were both educated on abuse prior to the incident. During an interview with the DON on 2/11/25 at 4:00 PM, confirmed that following a review of the video surveillance, CNA #1 did drag Resident #1 on the floor by his clothing down the hall and placed him in his room. LPN #1 should have stopped the physical abuse. A record review of the Face Sheet, revealed the facility admitted Resident #1 on 8/7/24 with current diagnoses including Epilepsy, Bipolar Disorder, and Mild Intellectual Disabilities. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/5/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated his cognition was moderately impaired. Further review revealed his vision was severely impaired. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 2/10/25: The Quality Assurance (Quality Assurance) Committee held an Emergency QA Meeting on 1/7/2025. The Quality Assurance Committee discussed the description of the incident. The QA committee discussed and approved training that was provided beginning on 1/3/25 at the beginning of the shift to all staff on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, and misappropriation of funds/Property to Individuals Receiving Services/Residents and Resident # 1 behavior Intervention protocol. The additional will be monitored per staff for continued effectiveness as it follows: Abuse/Neglect Policy & Adherence to Care Plan. Quality of corrections will be monitored daily by using a minimum of 5 (five) staff interviews per day 5 (five) days a week for 8 (eight) weeks by Nurse Manager and four Nurse Supervisors, beginning on 1/21/25. Quality of correction will also be monitored by observing interventions and interactions with patients 5 (five) days a week for 8 (eight) weeks by Nurse Manager and four Nurse Supervisosr, beginning on 1/21/25. Findings will be reported to QAPI (Quality Assurance Performance Improvement), beginning 2/13/25 times two months. On 1/3/25, all supervisors began training all the oncoming staff before the start of their shift on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, or Misappropriation of Funds/Property to Individuals Receiving Services/Residents, and Resident #1 Behavioral Intervention Protocol. No employee was allowed to work until there was in-service. On 1/3/2025 CNAs #1 and License Practical Nurse (LPN)#1 were placed on administrative leave pending completion of the investigation. LPN #1 was terminated from employment on 1/7/25 for observing physical abuse and failing to report it in a timely manner. CNA #1 was terminated from employment effective 1/7/25 for physically abusing Resident #1. The Investigator notified the State Agency by telephone on 1/3/25, the Attorney General's Office in writing of the incident on 1/3/25. Supervisors began In-servicing all employees on 1/3/25 prior to the beginning their shift. The in-services were completed on 1/7/25. The Immediate Jeopardy was removed on 1/8/25. The facility alleges all corrective actions were completed on 1/7/25 and the Immediate Jeopardy was removed on 1/8/25 prior to the state department of health entrance on 2/10/25. The facility alleges all corrective actions were completed on 1/7/25 and the IJ removed on 1/8/25 prior to the state agency's entrance on 2/10/25. Validation: The SA validated on 2/12/25, through interview and record review, that all corrective actions had been implemented as of 1/7/25, and the facility was in compliance as of 1/8/25, prior to the SA's entrance on 2/10/25.

Based on observation, interviews, record review, and facility policy review, the facility failed to report abuse in a timely manner for one (1) of three (3) sampled residents. Resident #1. Resident #1 was physically abused on 12/31/24 when a Certified Nurse Assistant (CNA) #1 dragged him by his shirt, the collar, and the shoulders of his jacket up the hallway into Resident #1 room. One nurse observed the abuse and failed to report it to the Director of Nursing (DON) or other staff. The facility's failure to report Resident #1's abuse placed this resident and all residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy and Substandard Quality of Care (SQC) which began on 12/31/24. The State Agency (SA) notified the Administrator of the IJ and SQC on 2/11/25 at 4:45 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 1/7/25, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 1/8/25. Findings include: A review of the facility policy titled Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, And/or Misappropriation of Funds/Property To Individuals Receiving Services/Residents, revised January 2024, revealed, .It is the policy .to affirm that all Individuals Receiving Services (IRS)/Residents have a right to be free from abuse .Definitions .Abuse: The willful infliction of physical pain, injury, or mental anguish, unreasonable confinement or the willful deprivation of services necessary to maintain physical and mental health .Mental Abuse: includes .humiliation, harassment .Prevention .(4) .will review, correct, and intervene in situations in which allegations of abuse, neglect .have potentially occurred .D. Reporting: (1) All employees .will immediately report any of the following (a) Witness of or discovery of any situation in which suspicion exits that an IRS/Resident has been the victim of abuse . A record review of LPN #1's written statement, dated 1/6/25, revealed that on 12/31/24 between 2:00 PM and 2:30 PM, Resident #1 was banging his head against the wall. CNA #1 proceeded to grab the resident by his neck and sweatshirt and drag him to his room. She felt like she was choking him, and she felt like this was abuse. She reported to the security officer and attempted to notify her DON, but she was not in her office. A record review of the Investigative Summary Report revealed that on 12/31/24 at 2:21 PM, Resident #1 was dragged on the floor by CNA #1. The resident was assessed on 1/3/25 when the allegation was submitted, and the Director of Nurses (DON) was notified. It was reported on 1/3/25 that on 12/31/24, CNA #1 dragged Resident #1 on the floor by the neck of his shirt to his room because the resident positioned himself on the floor in the hallway near the nurse's station. The resident was observed lying on the floor, hitting his head, and refusing to keep his protective helmet on. The investigation into the allegation yielded evidence that CNA #1 did drag the resident by the neck and shoulder sections of his jacket up the hallway into his room. Staff were placed on administrative leave pending investigation. Following the investigation, CNA #1 and License Practical Nurse (LPN) #1 were terminated on 1/7/25. At 2:43 PM on 2/10/25, during an interview with the Housekeeper, he confirmed that he did not report the abuse he witnessed to his manager because he assumed the other staff would have reported it. At 3:00 PM on 2/10/25, the SA observed surveillance video with the Administrator present. On 12/31/24 at 2:07 PM, CNA #1 was observed dragging/pulling Resident #1 by his arm/sleeve of his clothes, right side, approximately 16 feet to his room, and LPN #1 was observed walking beside the Resident #1 and CNA #1. At 12:01 PM on 2/11/25, during an interview with Registered Nurse (RN) #1, she confirmed that LPN #1 did not report that she had witnessed abuse of Resident #1 on 12/31/24 until 1/3/25, which was her next scheduled shift. RN #1 confirmed that the facility's policy is to immediately report any abuse to a supervisor, DON, or Administrator. At 12:30 PM on 2/11/25, during an interview with CNA #2, she confirmed Resident #1 was her assigned resident on 12/31/24. She revealed that she witnessed CNA #1 drag the resident down the hallway but stated that she did not have time to intervene. She reported the event was over in just a few seconds. LPN #1 advised her that she was going to report the episode to security campus, so CNA #2 did not report the episode to any supervisor. At 1:00 PM on 2/11/25, during a phone interview CNA #1, she confirmed she had dragged Resident #1 down the hallway by his clothing. CNA #1 stated that she did not report what had occurred on 12/31/24. At 3:40 PM on 2/11/25, in an interview with the Administrator , he confirmed that staff should have reported the abuse of Resident #1 immediately when it occurred on 12/31/24. At 4:00 PM on 2/11/25 during an interview with the DON, she confirmed the facility staff did not report the abuse of Resident #1 immediately and that it was not reported until 1/3/25. Following a review of the video surveillance, CNA #1 did drag Resident #1 on the floor by his clothing down the hall and placed him in his room. She stated that facility staff should have reported it to administrative staff when it happened. A record review of the Face Sheet, revealed the facility admitted Resident #1 on 8/7/24 with current diagnoses including Epilepsy, Bipolar Disorder, and Mild Intellectual Disabilities. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/5/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated his cognition was moderately impaired. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 2/10/25: The Quality Assurance (Quality Assurance) Committee held an Emergency QA Meeting on 1/7/2025. The Quality Assurance Committee discussed the description of the incident. The QA committee discussed and approved training that was provided beginning on 1/3/25 at the beginning of the shift to all staff on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, and misappropriation of funds/Property to Individuals Receiving Services/Residents and Resident # 1 behavior Intervention protocol. The additional will be monitored per staff for continued effectiveness as it follows: Abuse/Neglect Policy & Adherence to Care Plan. Quality of corrections will be monitored daily by using a minimum of 5 (five) staff interviews per day 5 (five) days a week for 8 (eight) weeks by Nurse Manager and four Nurse Supervisors, beginning on 1/21/25. Quality of correction will also be monitored by observing interventions and interactions with patients 5 (five) days a week for 8 (eight) weeks by Nurse Manager and four Nurse Supervisor, beginning on 1/21/25. Findings will be reported to QAPI (Quality Assurance Performance Improvement), beginning 2/13/25 times two months. On 1/3/25, all supervisors began training all the oncoming staff before the start of their shift on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, or Misappropriation of Funds/Property to Individuals Receiving Services/Residents, and Resident #1 Behavioral Intervention Protocol. No employee was allowed to work until there was in-service. On 1/3/2025 CNAs #1 and License Practical Nurse (LPN)#1 were placed on administrative leave pending completion of the investigation. LPN #1 was terminated from employment on 1/7/25 for observing physical abuse and failing to report it in a timely manner. CNA #1 was terminated from employment effective 1/7/25 for physically abusing Resident #1. The Investigator notified the State Agency by telephone on 1/3/25, the Attorney General's Office in writing of the incident on 1/3/25. Supervisors began In-servicing all employees on 1/3/25 prior to the beginning their shift. The in-services were completed on 1/7/25. The Immediate Jeopardy was removed on 1/8/25. The facility alleges all corrective actions were completed on 1/7/25 and the Immediate Jeopardy was removed on 1/8/25 prior to the state department of health entrance on 2/10/25. The facility alleges all corrective actions were completed on 1/7/25 and the IJ removed on 1/8/25 prior to the state agency's entrance on 2/10/25. Validation: The SA validated on 2/12/25, through interview and record review, that all corrective actions had been implemented as of 1/7/25, and the facility was in compliance as of 1/8/25, prior to the SA's entrance on 2/10/25.

Based on interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for a resident with behaviors for one (1) of three (3) sampled residents. Resident #1. Resident #1 was physically abused on 12/31/24 when Certified Nurse Assistant (CNA) #1 dragged him by his shirt, the collar, and the shoulders of his jacket up the hallway into Resident #1 room. One nurse observed the abuse and failed to intervene, allowing the abuse to escalate. The facility's failure to implement the care plan interventions placed this resident and all residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 12/31/24. The State Agency (SA) notified the Administrator of the IJ on 2/11/25 at 4:45 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 1/7/25, the SA determined the IJ to be Past-Non-Compliance (PNC) and the IJ was removed on 1/8/25, prior to the SA's entrance on 2/10/25. Findings include: A review of the facility policy titled Interdisciplinary Care Plan Team, with a reauthorized date of August 2024, revealed, .The purpose of the team is to define and coordinate the treatment for each resident . A record review of the Care Plan revealed, .Problem Onset 8/31/24: Potential For Mood and Behavioral Problem . with a goal of Resident will not have increased and mood behavior problem during the quarter, 5/3/25.Approaches: Resident to wear helmet at all times when out of bed for safety (D/T) due to hitting head on floors/walls. Redirect resident if he has inappropriate behaviors and involve him in activities . A record review of the Investigative Summary Report, dated 1/7/25, revealed that on 12/31/24 at 2:21 PM, Resident #1 was dragged on the floor by CNA #1. The resident was assessed on 1/3/25 when the allegation was submitted, and the Director of Nurses (DON) was notified. It was reported on 1/3/25 that on 12/31/24, CNA #1 dragged Resident #1 on the floor by the neck of his shirt to his room because the resident positioned himself on the floor in the hallway near the nurse's station. The resident was observed lying on the floor, hitting his head, and refusing to keep his protective helmet on. The investigation into the allegation yielded evidence that CNA #1 did drag the resident by the neck and shoulder sections of his jacket up the hallway into his room. Staff were placed on administrative leave pending the investigation and following the investigation, CNA #1 and License Practical Nurse (LPN) #1 were terminated on 1/7/25. On 2/11/25 at 10:09 AM, during an interview Registered Nurse (RN)/Minimum Data Set (MDS), she confirmed that she expects all staff to follow the Comprehensive Care Plans' interventions for residents. The care plans are person-centered and address residents' needs and safety. She explained that care plans are accessible to staff through care plan books at each nursing area and are reviewed periodically. The MDS nurse reported that in-service training is provided to the staff regarding following care plans, but acknowledged that some staff may not consistently follow them and disciplinary action is taken when necessary. During an interview with the Director of Nursing on 2/11/25 at 4:00 PM, it was revealed that the unit staff should have followed the care plan interventions for the safety of Resident #1. She expected all staff to follow the residents' care plans, which are designed to provide each resident with care based on their individual needs. The DON acknowledged that Resident #1 has a documented history of self-injurious behavior (hitting his head on walls and floors), which is why he wears a helmet for protection. She confirmed that the resident's care plan includes redirection techniques, such as offering snacks, drinks, or engaging him in activities when he exhibits such behavior. She agreed that if these interventions had been implemented, the incident may have been prevented. On 2/11/25 at 1:00 PM, during a phone interview with CNA #1, she reported that Resident #1 was not her assigned resident, so she did not follow the care plan on re-directing him, she just responded by dragging him to his room. A record review of the Face Sheet, revealed the facility admitted Resident #1 on 8/7/24 with current diagnoses including Epilepsy, Bipolar Disorder, and Mild Intellectual Disabilities. A record review of the MDS with an Assessment Reference Date (ARD) of 11/5/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated his cognition was moderately impaired. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 2/10/25: The Quality Assurance (Quality Assurance) Committee held an Emergency QA Meeting on 1/7/2025. The Quality Assurance Committee discussed the description of the incident. The QA committee discussed and approved training that was provided beginning on 1/3/25 at the beginning of the shift to all staff on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, and misappropriation of funds/Property to Individuals Receiving Services/Residents and Resident # 1 behavior Intervention protocol. The additional will be monitored per staff for continued effectiveness as it follows: Abuse/Neglect Policy & Adherence to Care Plan. Quality of corrections will be monitored daily by using a minimum of 5 (five) staff interviews per day 5 (five) days a week for 8 (eight) weeks by Nurse Manager and four Nurse Supervisors, beginning on 1/21/25. Quality of correction will also be monitored by observing interventions and interactions with patients 5 (five) days a week for 8 (eight) weeks by Nurse Manager and four Nurse Supervisor, beginning on 1/21/25. Findings will be reported to QAPI (Quality Assurance Performance Improvement), beginning 2/13/25 times two months. On 1/3/25, all supervisors began training all the oncoming staff before the start of their shift on Resident Rights, Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, or Misappropriation of Funds/Property to Individuals Receiving Services/Residents, and Resident #1 Behavioral Intervention Protocol. No employee was allowed to work until there was in-service. On 1/3/2025 CNAs #1 and License Practical Nurse (LPN)#1 were placed on administrative leave pending completion of the investigation. LPN #1 was terminated from employment on 1/7/25 for observing physical abuse and failing to report it in a timely manner. CNA #1 was terminated from employment effective 1/7/25 for physically abusing Resident #1. The Investigator notified the State Agency by telephone on 1/3/25, the Attorney General's Office in writing of the incident on 1/3/25. Supervisors began In-servicing all employees on 1/3/25 prior to the beginning their shift. The in-services were completed on 1/7/25. The Immediate Jeopardy was removed on 1/8/25. The facility alleges all corrective actions were completed on 1/7/25 and the Immediate Jeopardy was removed on 1/8/25 prior to the state department of health entrance on 2/10/25. The facility alleges all corrective actions were completed on 1/7/25 and the IJ removed on 1/8/25 prior to the state agency's entrance on 2/10/25. Validation: The SA validated on 2/12/25, through interview and record review, that all corrective actions had been implemented as of 1/7/25, and the facility was in compliance as of 1/8/25, prior to the SA's entrance on 2/10/25.

Based on observation, staff interview, record review, and facility policy review, the facility failed to record daily temperatures for refrigerators and a freezer for the last six (6) days prior to survey entrance on 01/08/24 and failed to date and label stored food in the facility refrigerator for one (1) of two (2) kitchen observations. The deficient practice had the potential to affect 50 of 59 residents in the facility. Findings include: A review of the facility's policy, Food and Nutrition Services, dated January 2023, revealed, .The purpose of this policy is to provide guidelines for the creation and maintenance of an environment that is physically and bacteriologically safe for the storage, preparation, serving, and disposal of food .Procedure . (1) Food is stored in the original packaging and is properly labeled .B. Food Handling and Storage (1) Food will be held at the appropriate temperature to maintain quality and prevent the growth of harmful bacteria. (a) Immediately upon receipt, cold foods will be placed in the refrigerator or on ice to maintain 41 degrees Fahrenhiet or colder during holding . (2) Refrigerator and freezer thermometers will be monitored once daily and documented on the Refrigerator Temperature Record Form .and the Freezer Temperature Record Form .(7) Opened containers will be labeled with the date the item was opened and the date of expiration . An observation and interview, on 01/08/24 at 11:15 AM, revealed a refrigerator in the front room of the kitchen was registering at 54 degrees on the thermometer located outside of the refrigerator, which was more than 40 degrees. The rubber gasket around the refrigerator door did not properly seal the refrigerator door when closed. Dietary Aide (DA) #3 confirmed that the gasket has not sealed in a long time and maintenance was aware. Record review of the Freezer Temperature Log for Jan (January) 2024 revealed there were no temperatures recorded on the 5th, 6th, or 7th. Record review of the Refrigerator Temperature Log for [DATE], for the refrigerator located on the Front revealed there were no temperatures recorded for the 3rd, 4th, 5th, 6th, or 7th. Record review of the Refrigerator Temperature Log for [DATE], for the refrigerator located on the Back revealed there were no temperatures recorded for the 5th, 6th, or 7th. On 1/8/24 at 11:18 AM, in an interview with DA #3, she confirmed that freezer and refrigerator temperature should be logged daily and if the food was not stored at a certain temperature, it could make the residents sick. An observation on 1/08/24 at 11:18 AM, revealed the food warmer in the front room in the kitchen contained bacon and toast that was wrapped in aluminum foil. There was no identifying label or date on the container. Upon observation of the back there was a an eight (8) ounce Gatorade drink with a straw inside it on the top shelf of the refrigerator, with no label indicating the date it was opened. There was a serving tray with individual prepared bowls of soup that did not have an identifying label and was not dated. An interview, on 01/08/24 at 2:00 PM, with the Dietary Account Manager confirmed that the refrigerator and freezer temperatures logs had omissions and should be documented daily to ensure food items remain at the correct temperature and does not make anyone sick. An interview on 01/09/24 at 09:30 AM, with the Maintenance Director confirmed that he was aware of the gasket not sealing on the refrigerator in the kitchen and that one had been ordered but not received at this time. The Maintenance Director confirmed that without the proper gasket in the refrigerator the temperature would not be 40 degrees or below and that food could be ruined. An interview on 01/11/23 at 08:30 AM, with Dietary Account Manager confirmed that she was aware of the issue with the gasket not working properly on the refrigerator and that it would not remain at a temperature of 40 degrees or below. The Dietary Account Manager confirmed that food could ruin and make someone sick if the refrigerator did not remain at the correct temperature. She stated that food must be labeled and dated and no personal food or drinks should be in the refrigerator.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident had a dignified dining experience for (1) one of seven (7) resident dining observations. (Resident #160) Findings include: Review of the facility's policy, Rights and Responsibilities of Residents, revised October 2023, revealed, .It is the policy of (Proper Name) to protect and support the fundamental human, civil, and constitutional rights of each resident .Procedure . (10) Treated with respect and full recognition of their dignity and individuality . During an interview and observation on 1/8/24 at 12:05 PM, Resident #160 was in her room and had not received her meal tray. She stated that her roommate had received her meal tray and had already finished eating lunch. Resident #160 said that for the last week, her tray has been served about an hour later than her roommate, and she was unsure as to why this has occurred. She expressed that she did not believe it was right that she had to watch her roommate eat and had to wait for her food to be served. In an interview with Certified Nurse Aide (CNA) #2, on 1/8/24 at 12:10 PM, she revealed that a CNA had recognized that Resident #160's meal tray was not on the meal cart and was currently at the Dietary Department to get her meal tray. She confirmed that Resident #160's meal tray should have been on the meal cart that was delivered to the hall at 11:15 AM and the roommate should not have been served until both meal trays were available. CNA #2 also confirmed that it was possible that Resident #160 would be bothered by not having food to eat while watching her roommate enjoy her meal. During an observation and interview on 1/8/24 at 12:15 PM, CNA #1 delivered and set up the lunch meal tray for Resident #160. She confirmed that she had delivered the roommate's meal tray earlier and that Resident #160 did not get a tray when the roommate's tray was delivered. CNA #1 explained that she did not check the cart for Resident #160's meal tray after serving the roommate because she passed the trays in the order they were set up on the cart. CNA #1 did not respond when asked how this practice affected Resident #160. An interview with the Director of Nursing (DON) on 1/08/24 at 12:50 PM, she revealed Resident #160 should not have had to wait an hour for her meal tray, confirming the staff that delivered the roommates tray should have delivered Resident #160's tray next and if it was not on the cart the staff should have gone to dietary and requested it then. The DON also confirmed that Resident #160 could have been bothered by having to watch her roommate eat. An interview with Dietary Manager #1 and Dietary Account Manager #2 on 1/09/24 at 2:33 PM, they both revealed they were not aware that Resident #160 had been receiving her meal trays late and confirmed Resident #160 should not have had to wait for an hour for her meal tray to be served, stating if staff would have come to dietary sooner the dietary staff would have fixed the resident a tray. Record review of the Face Sheet revealed the facility admitted Resident #160 to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease and Anxiety. Record review of the Admission Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/2/23, revealed that Resident #160 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that she was cognitively intact.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by staff failing to correctly wear a face mask on one (1) of four (4) days of survey and failed to perform hand hygiene during wound care for one (1) of five (5) wounds observed. (Resident # 57) Findings include: A review of the facility's policy Pandemic Influenza/Coronavirus Disease 2019- Infection Control Practices, revised September 2023, revealed .It is the policy of (Proper Name) to control and prevent pandemic influenza/coronavirus disease 2019 (COVID-19) in Individuals Receiving Services (IRS)/residents, employees, and visitors by providing guidelines for infection control practices.Procedure: A.) The primary strategies for preventing COVID-19 are: (2) Use of infection control measures to prevent transmission . An interview with the Director of Nursing (DON) upon entrance to the facility on [DATE] at 11:05 AM, she revealed the facility was in an active COVID-19 outbreak with one positive resident on the Dogwood Hall rooms 101-131 and all staff were using extra precautions and wearing masks. During an observation and interview on 1/08/24 at 12:15 PM, Certified Nurse Aide (CNA) #1 exited a resident's room on the Dogwood Hall and was wearing a face mask that did not cover her nose. CNA #1 revealed that there was one resident with COVID-19 on the hall and confirmed the staff working on that hall were required to wear face masks. She also confirmed her mask was not covering her nose because it made it hard for her to breathe. She stated that she was aware that the proper way to wear a face mask was to cover the mouth and the nose to prevent the spread of infection. An observation on 1/8/24 at 12:30 PM, revealed CNA #1 exited a resident's room, walking down the Dogwood Hall, and the top of the face mask was resting on her upper lip, only covering her mouth, leaving her nose exposed. During an observation and interview on 1/08/24 at 12:38 PM, CNA #1 exited another resident's room with her face mask covering her mouth, and her nose was not covered. CNA #1 confirmed she was not wearing her mask correctly and stated, well it just keeps sliding down, I can't help it. An interview with the DON on 1/08/24 at 12:45 PM, she confirmed all staff should wear a face mask that covered the mouth and nose to reduce the possible transmission of infections. An interview with the Infection Preventionist (IP) on 1/09/24 at 2:11 PM, she confirmed the facility was in active outbreak status and staff are wearing masks. The IP revealed the purpose of adhering to infection control prevention measures such as masks is to protect residents and staff from infection and failing to wear a mask correctly could place residents and staff at risk of acquiring an infection. 47158 Resident #57 A review of the facility's policy Standard Precautions, revised September 2023, revealed Policy .Employees will utilize Standard Precautions on all residents .Procedure .C. 1. Gloves .(c) Gloves will . (iv) Be removed and hands will be washed immediately upon glove removal . Record review of the Face Sheet for Resident #57 revealed he was admitted by the facility on 7/13/23 with a diagnosis of Diffuse Traumatic Brain Injury (TBI). A Record review the Physician Orders for the month of January 2024 revealed Resident #57 had a physician's order, dated 12/21/23 to Clean wound to left heel pressure ulcer with normal saline, pat dry, paint with betadine, cover with kerlix change daily . On 1/10/24 at 11:55 AM, during an observation of wound care by Licensed Practical Nurse (LPN) #1, she cleaned the wound on Resident #57's left heel. She then removed her gloves and applied clean gloves without washing or sanitizing her hands. LPN #1 swabbed the wound with a betadine swab and covered it with a gauze dressing. Upon interview with LPN #1 on 1/10/24 at 12:00 PM, she agreed that she should have sanitized her hands before applying clean gloves and continued with wound care. She stated failure to sanitize her hands could put the resident at risk of acquiring an infection. Upon interview with the Director of Nursing (DON) on 1/10/24 at 12:10 PM, she agreed that LPN #1 should have sanitized her hands prior to applying clean gloves. She verified that failure to sanitize hands could place the resident at risk for infection.

Based on interviews, record review, and facility policy review, the facility failed to ensure residents had readily available and reasonable access to their personal funds, seven (7) days a week, for four (4) of 15 residents sampled. Resident #8, Resident #10, Resident #34, and Resident #45 Findings Included: A review of the facility's Money Policy for Individuals Receiving Services/Residents, revised March 2020, revealed, . F. Money Call is the time established by the Division Director or Fiscal Services Director, during which, an IRS (Individual Receiving Service)/resident is distributed money from his/her RFMS (Resident Fund Management Service) account, held by their designated money custodian .G. Money day is one of the scheduled days when Patient Accounts issues cash and checks from the (Proper Name of Facility) Resident Trustee Account to the money custodians . Resident #8 On 10/17/22 at 12:53 PM, during an interview with Resident #8, he stated that they can only get their personal money on Tuesdays because the person who deals with the money is not there on the weekends. A record review of the Face Sheet of Resident #8 revealed he was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/14/22 revealed Resident #8 had a Brief Interview of Mental Status (BIMS) score of 13, indicating he had no cognitive impairment. Resident #10 On 10/17/22 at 12:19 PM, in an interview with Resident #10, she stated she can only get money on Tuesday. She stated Tuesday is Money Call Day. She explained that no one is here to give money on weekends. Record review of the Face Sheet of Resident #10 revealed the facility admitted her on 5/3/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly MDS with an ARD of 7/26/22 for Resident #10 revealed she had a BIMS score of 15, which indicated she was cognitively intact. Resident #34 On 10/17/22 at 12:00 PM, during an interview with Resident #34, he stated that they get their money every Tuesday morning. A record review of the Face Sheet revealed the facility admitted Resident #34 on 5/08/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #34's Annual MDS with an ARD of 9/02/22 revealed that the resident has a BIMS of 9, which indicated he had moderate cognitive impairment. Resident #45 On 10/17/22 at 12:11 PM, Resident #45 stated she can only get money out of her account on Tuesday. She stated they call it Money Call and it is on Tuesday only. She stated they cannot get money on weekends. Record review of the Face Sheet revealed the facility admitted Resident #45 on 2/16/05 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly MDS with an ARD of 9/16/22 revealed a BIMS score of 15, which indicated Resident #45 was cognitively intact. On 10/17/22 at 3:35 PM, during an interview with Licensed Practical Nurse (LPN) #1, she stated that the Money Custodian does a Money Call every Tuesday at 9:00 AM. On 10/18/22 at 8:50 AM, the SA heard an announcement on the facility's intercom system for Money Call in which the residents were to come to the dayroom to receive their money. On 10/18/22 at 9:03 AM, during an interview with the Money Custodian, she stated that if she knows that residents are going out on the weekend, the Social Worker will send her an email letting her know who wants what amount of money. She stated that she always makes sure that the residents receive it. She stated that the residents are used to coming to receive funds on Tuesdays, so they make it available every Tuesday. She confirmed that she is only at the facility Monday through Friday, so she gives them what they ask for during those days. On 10/18/22 at 9:13 AM, during an interview with the Director of Nursing (DON), he stated that Money Call is a designated day that the residents come get their money. He revealed it could be for an outing, or for some, they just like to have some money on them. He stated that the person that handles the money gives it to them anytime of the week, Monday through Friday. On 10/18/22 at 09:18 AM, during an interview with the Administrator, he stated that Money Call is when the money custodian comes, and the residents come pick up their spending money for trips or when they go out on pass. He stated that the residents can receive their money from her anytime Monday through Friday. On 10/18/22 at 09:20 AM, during an interview with the Head Administrator, he stated that if the residents request money ahead of time by Friday, they will be able to get it for the weekend. A record review of the Trial Balance with Balances as of 10/22/22 revealed Resident #8, Resident #10, Resident #34, and Resident #45 were listed as having a personal fund account with the facility

Based on interviews, record review, and facility policy review, the facility failed to accurately code the Admission Minimum Data Set (MDS) related to a resident's reentry into the facility from an acute care hospital for one (1) of 17 residents reviewed for MDS accuracy. Resident #46. Findings Included: A review of the facility's Minimum Data Set (MDS) policy, revised August 2022, revealed, .2. Purpose: The purpose of this policy is to .establish the framework for organizing an individual plan of care . A record review of the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019, revealed, .A1800: Entered From .Item Rational .Understanding the setting that the individual was in immediately prior to facility .reentry informs care planning and may also inform discharge planning and discussions . A record review of the Face Sheet revealed the facility admitted Resident #46 on 9/29/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the facility's document, Notice of Bed Hold and Readmission, dated 6/13/22, revealed Resident #46 was transferred to a local acute care hospital. A record of the Discharge MDS with an Assessment Reference Date (ARD) of 6/13/22 revealed A2100 was coded as 3. Acute Hospital which indicated Resident #46 had been transferred to an acute care hospital. A record review of the Admissions MDS with an ARD of 6/27/22 revealed the assessment was coded as a Reentry from Another nursing home or swing bed, which was not consistent with the discharge assessment or the Notice of Bed Hold and Readmission document which indicated Resident #46 was transferred to an acute hospital on 6/13/22. A record review of the facility's document, Notice of Bed Hold and Readmission, dated 8/24/22 revealed Resident #46 was transferred to a local acute care hospital. A record review of the Discharge MDS with an ARD of 8/24/22 revealed A2100 was coded as 3. Acute Hospital which indicated Resident #46 had been transferred to an acute care hospital. A record review of the Admissions MDS with an ARD date of 8/27/22 revealed the assessment was coded as a Reentry from Another nursing home or swing bed, which was not consistent with the discharge assessment or the Notice of Bed Hold and Readmission document which indicated Resident #46 was transferred to an acute hospital on 8/24/22. On 10/20/22 at 1:50 PM, during an interview with Registered Nurse (RN) #1/MDS Nurse, she stated Resident #46 returned to the facility on [DATE] and 8/27/22 from an acute care hospital. She confirmed that the Admission Assessments should have been coded for the resident as entering from an acute hospital instead of from another nursing home or swing bed. On 10/20/22 at 2:45 PM, during an interview with the Administrator, he stated the MDS should have been coded correctly, and it is very important. On 10/20/22 at 2:54 PM, during an interview with the Director of Nursing (DON), he confirmed the MDS should have been coded correctly and that it is important.

Based on interviews, record review, and facility policy review, the facility failed to provide mail delivery on Saturdays for three (3) of 15 sampled residents and had the potential to affect 57 of 57 residents residing in the facility. Resident #10, Resident #45, and Resident #46 Findings Included: Review of the facility's policy Mail Distribution, with a revision date of May 2021, revealed, 1. Policy It is the policy of (Proper Name of Facility) that Mail Room staff will distribute and process all internal, external, and accountable mail that is delivered to the .Nursing Home Division (NHD) .9. USPS (United State Postal Service) delivers all NHD residents incoming mail to the facility mailbox on Saturday to ensure residents receive mail six days a week. Mail will be sorted and disturbed to the residents and or the residents Social Worker . Resident #10 Record review of the Face Sheet revealed Resident #10 was admitted by the facility on 5/3/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/26/22, revealed Resident #10 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated she was cognitively Intact. On 10/20/22 at 1:00 PM, in an interview with Resident #10, she stated she has never received mail on Saturday. Resident #45 Record review of the Face Sheet revealed Resident #45 was admitted by the facility on 2/16/05 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly MDS, with an ARD of 9/16/22, revealed Resident #45 had a BIMS score of 15, which indicated she was cognitively intact. On 10/20/22 at 11:32 AM, in an interview with Resident #45, she stated she does not get mail on Saturdays and that she has never received mailed on Saturdays since she was admitted to the facility. Resident #46 On 10/18/22 at 3:50 PM, Resident #46 stated that he does not receive his mail on the weekends because social services are not here. He stated that they usually get it on the following Monday when Social Services come back to work. Record review of the Face Sheet revealed Resident #46 was admitted by the facility on 9/29/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly MDS, with an ARD of 09/20/22, revealed Resident #46 had a BIMS score of 11, which indicated he had moderate cognitive impairment. On 10/20/22 at 1:31 PM, in an interview with the Social Worker (SW), she explained the facility has a Post Office Box. Also, some of the facility's mail will go to the mailroom on the Main Campus and that transportation will bring it over to the facility. She stated the mail is received at the front office and is sorted by the Administrative Assistant, who brings the mail to the SW office to be passed out to the residents. She confirmed that this is done Monday through Friday and the mail that comes in on weekends is not given to the residents until Monday. On 10/20/2022 at 3:35 PM, in an interview with the Administrator, he stated the mail should be issued on Saturdays because receiving mail makes the residents happy and it is good for their psychosocial health. He commented that the facility will work to ensure that residents can get their mail on Saturdays.

Based on resident and staff interviews, record review, and review of the facility policy, the facility failed to assist three (3) of six (6) residents who wanted to vote in the Governor's election on 11/6/19, Resident #8, Resident #36, and Resident #31. Findings include: Review of the facility's policy, Voting Rights, dated 12/2014, revealed: We will assist the resident in exercising their right to vote by mail. In an interview with the residents, during a group meeting, on 11/5/2019 at 3:00 PM, three (3) of the six (6) residents said they did not get to vote in the general election. They expressed the desire to vote. Review of the most recent Minimum Data Sets (MDS) revealed Resident #8, Resident #36, and Resident #1 had a Brief Interview Mental Status (BIMS) score of 15, which indicated no cognitive impairment. In an interview on at 11/05/19 at 3:35 PM, the Social Worker stated the residents did not say anything about wanting to vote. She confirmed the policy stated residents had the right to vote, but no one came to her and asked to vote.

Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible spread of infection during medication administration for two (2) of three (3) observations. Findings Include: Record Review of the facility's policy, Nursing Services: Standards of Care, revised (MONTH) 2019, revealed it is the policy of the facility that nursing staff will accept standard nursing practices for procedures not specifically defined by the facility Policy and Procedure Manual. The facility operates and provides services in compliance with current federal, state, and local laws, regulations, codes and professional standards of practice, that apply to the facility and types of services provided. Observation on 11/05/19 at 10:00 AM, revealed LPN #1 put gloves into her pocket prior to administering Percutaneous Endoscopic Gastrostomy (PEG) tube medication. LPN #1 washed her hands, pulled gloves out of her pocket, and administered the PEG tube medications to Resident #48. In an interview on 11/05/19 at 11:17 AM, LPN #1 confirmed she placed the gloves in her pocket prior to administering medication. LPN #1 stated she placed other things in her pocket, and pulled out car keys and pens, and stated putting the gloves in her pocket with these items could be a potential source of infection easily spread to residents. LPN #1 said, It's a habit. Observation on 11/06/19 at 9:00 AM, of medication Administration with LPN #2, revealed the nurse placed eye drops, [MEDICATION NAME] INH inhaler, and a 10 pack of [MEDICATION NAME] in her pocket. LPN #2 washed her hands, applied gloves, removed the medication from her pocket, and administered the medication to Resident #18. Interview on 1/06/19 at 11:23 AM, with LPN #2, confirmed she placed the eye drops, [MEDICATION NAME] INH and [MEDICATION NAME] in her pocket prior to administering the medication to Resident #18. LPN #2 stated she never thought about all the things that goes into her pocket, which is a dirty environment. LPN #2 stated this habit could cause infection to the residents. Interview on 11/07/19 at 11:28 AM, with Registered Nurse RN #1/Facility Educator, revealed she does the training with staff about infection control. RN #1 said the facility policy is to not place gloves, or medication, in their pockets. Interview on 11/07/19 at 11:31 AM, with The Director of Nursing (DON), confirmed both nurse's failed to prevent the possible spread of infection by placing gloves and medication in their pocket, prior to medication administration. Record Review of the facility's in-service, dated 4/1/2019, revealed Licensed Practical Nurse (LPN) #1 was trained on Inflection Prevention/Communicable Disease/Personal Hygiene. Record Review of the facility's in-service, dated 5/21/2019, revealed LPN #1 was trained on Infection Prevention. Record Review of the facility's inservice, dated 7/23/2019, revealed LPN #2 was trained on Infection Prevention.

Based on observation, interview, and review of the facility policy, the facility failed to ensure the dietary staff practiced safe and sanitary techniques between cleaning kitchen equipment and preparing food. This deficient practice had the potential to affect widespread number of residents receiving food from the kitchen. Findings include: A review of the facility's policy titled, Handwashing Process, indicated the information is based on the FDA (Food and Drug Administration) Food Code 2013. The document indicated to wash hands when changing tasks. The document indicated to wash hands after handling chemicals. The document indicated to change gloves before beginning a new task. Review of the facility's Personal Hygiene policy indicated to Wear a hairnet or cap to restrain all hair. For anyone with facial hair wear a beard and mustache restraint. The policy indicated the information is based on the FDA (Food and Drug Administration) Food Code 2013. During an observation in the kitchen, on 10/18/15 at 11:30 AM., Dietary Staff #4 was observed cleaning a microwave oven on a table that sat next to a tray of bread with meat on the bread. Dietary Staff #4 was wearing a pair of blue colored gloves, and was wearing a beard net that did not cover his moustache. Dietary Staff #4 was using a rag to wipe out the microwave oven. Dietary Staff #4 would dip the rag into a green bucket and then wipe off the microwave oven. The meat was arranged on top of one slice of bread with another slice of bread beneath the slice with the meat on it. These slices were arranged in four rows with the rows running across the tray. Dietary Staff #4 stopped cleaning the microwave oven and proceeded to the tray with the sandwich preparations. Dietary Staff #4 started handling the bread by picking up the bread to arrange the bottom slice over the slice of bread with the meat on it. Dietary staff #4 did not stop to change his gloves nor wash his hands. He just went right to handling the bread with the same gloved hands he had used to clean the microwave oven. In an interview, on 10/15/18 at 11:30 AM., Dietary Staff #4 said he was making sandwiches for the residents' bed time snack. The surveyor brought this to the attention of Dietary Staff #1, who had been identified by the Dietician as the supervisor in the kitchen. Dietary Staff #1 left the tray line and went to the other room were Dietary Staff #4 was making the sandwiches and told Dietary Staff #4 that he needed to throw out all the sandwiches because he was making the sandwiches with the same gloved hands he had used to clean the microwave oven. In an interview, on 10/15/18 at 11:40 AM, Dietary Staff #1 was questioned regarding if Dietary Staff #4 needed to have his beard net pulled over his moustache. Dietary Staff #1 went back to Dietary Staff #4 and instructed the employee to pull his beard net over his nose. Later in the afternoon the Assistant Dietary Manager reported that Dietary Staff #4 had been retrained. During an interview, with Dietary Staff #1, on 10/15/18 at 11:45 AM, the supervisor presented a training attendance record, dated 9/15/18, showing Dietary Staff #4 had participated in proper hand washing and glove use.

Based on observation, policy review, resident and staff interview, the facility failed to provide privacy during Resident #25's care, for one (1) of 51 resident observations. Findings include: A review of the facility's policy titled, Rights and Responsibilities of the Residents, with the most recent revision date of (MONTH) (YEAR), revealed resident's were to be, treated with respect and full recognition of his/her dignity and individuality, including privacy in treatment and care for his/her personal needs. An observation, on 10/15/18 at 4:06 PM, of Resident #25, revealed the door to the resident's room was open, and the resident was sitting in the wheelchair in front of the sink, while Certified Nursing Assistant (CAN) #1 was shaving the resident's chin. An interview, on 10/16/18 at 8:51 AM, with Resident #25, revealed most of the time they provide privacy/dignity when providing care by shutting the door of curtain, but sometimes they don't. Resident #25 reported she preferred the door to be shut when they were shaving her chin. An interview, on 10/16/18 at 2:13 PM, with CNA #1, revealed she would normally close the door to shave the resident, but CNA #1 reported she did not do so on 10/15/18. CNA #1 reported she should have had the door shut while providing Resident #25's care. A review of the facility's Clinical Inservices, orientation packet, and Annual Competency packet revealed the staff had been trained on the importance of dignity and privacy by Registered Nurse (RN) #3. On 10/17/18 at 3:23 PM, an interview with the Director of Nurses (DON) revealed she expected the staff to close the door while providing care. The DON reported that leaving the door open while shaving a resident was not acceptable. On 10/17/18 at 3:23 PM, an interview with RN #2, revealed it was undignified to leave the door open while shaving a resident. RN #2 reported this was not acceptable to provide patient care with the door open. On 10/17/18 at 4:25 PM, an interview with RN #3 revealed she usually addressed dignity and privacy monthly in the monthly inservices. RN #3 reported she would expect the CNA to shut the door or curtain when providing care such as shaving. RN #3 reported she provided competency training for all employees annually, and upon hire that addresses dignity and privacy. A review of the facility's Face Sheet, for Resident #25, revealed the facility admitted the resident, on 09/3/14, with the included [DIAGNOSES REDACTED]. Review of Resident #25's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/14/18, revealed a Basic Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Further review of the MDS revealed Resident #25 required extensive assistance with one person physical assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident #25 had Range of Motion (ROM) limitation to one side of her lower extremities. Resident #25 was able to make herself understood to others, and able to understand others.

Based on observation, record review, facility policy review and staff interview, the facility failed to follow the care plan related to Resident #42's use of oxygen, for one of six (1 of 6) resident care plans reviewed for oxygen therapy. Findings include: A review of the facility's policy titled, Interdisciplinary Care Plan, with a revision date of (MONTH) (YEAR), revealed: Policy: It is the policy of East Mississippi State Hospital (EMST) Nursing Home Division (NHD) 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. Procedure: 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, and on significant change. This revision will reflect the identified needs, strengths, weaknesses, and goals as well as the preferences of the resident. The care plan will also be revised anytime there is an acute change in the condition of the resident. A review of Resident #42's Comprehensive Care Plan, dated 07/05/18, for the Problem/Need potential alteration in vital signs, and shortness of breath related to [DIAGNOSES REDACTED]. The Approaches included oxygen (02) via nasal cannula (NC) at two (2) liters per minute (L/min) as needed (PRN) for shortness of breath (SOB). An observation and interview, with Resident #25, on 10/15/18 at 11:20 AM, revealed the resident had 02 on at 3 L/min per NC via an O2 concentrator. Interview with Resident #42 at this time revealed she was not having any SOB at this time, and she was not sure what her oxygen was supposed to be on. Resident #42 reported the nurses take care of that. An observation and interview, with Resident #42, on 10/17/18 at 8:47 AM, revealed she was receiving 02 at 4 L/min via a NC. During the observation Resident #42 did not appear to be having any Shortness of Breath (SOB). An interview at this time with Resident #42 revealed she was not having any SOB. A review of Resident #42's (MONTH) (YEAR) physician's orders [REDACTED]. The monthly orders were signed by the Nurse Practitioner (NP), on 10/01/18. A review of the Routine Nursing Orders, signed by the Physician on 6/21/18, revealed an order for [REDACTED]. If signs of respiratory distress (cyanosis, respiratory rate greater then 30, 02 sat below 85%, unconscious) send to the ER. A record review of Resident #42's Minimum Data Set ( MDS), dated [DATE], revealed the resident was coded for the use of 0xygen Therapy. A record review of Resident #42's Nurses Notes, dated 10/15/18 at 2:00 AM, revealed an 02 saturation of 91% on room air. The Nurses Note did not address if the resident was having any SOB, or if the nurse applied oxygen for the oxygen saturation of 91%. A record review of the Resident #42's Nurses Notes, dated 10/17/18 at 7:00 AM, revealed an O2 saturation of 96% with O2 at 2 L/min via NC. The Nurses Note did not reveal if Resident #42 exhibited any SOB at this time. A record review of Resident #42's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. If are sats below 89%, notify the physician or NP. If signs of respiratory distress (cyanosis, respiratory rate greater then 30, 02 sat below 85%, unconscious) send to the ER. Further review of the MAR indicated [REDACTED]. On 10/17/18 at 8:49 AM, an interview with Licensed Practical Nurse (LPN) #1, revealed the resident's oxygen should be at 2L/MIN according to the physician's orders [REDACTED].#1 stated the oxygen was on at 2L/min when she checked it earlier this morning. LPN #1 was observed to walk to Resident #42's room, and verified the oxygen was on 4L/min. On 10/17/18 at 8:54 AM, an interview with Registered Nurse (RN) #1 revealed the standing orders are for 02 at 2-4 LPM via NC PRN. RN #1 reported she was not sure why there was another order for O2 at 2L/min PRN on the current monthly orders. RN #1 reported they can use the standing orders if they need to. On 10/17/18 at 9:25 AM, an interview with the Director of Nurses (DON) revealed the physician's orders [REDACTED]. The DON reported the orders needed to be cleaned up. The DON revealed the staff was not following the resident's care plan, and she would expect the staff to follow the care plan. A review of the facility's Face Sheet, for Resident # 42, revealed the facility admitted the resident, on 10/30/15, with the included [DIAGNOSES REDACTED]. Review of Resident #42's Quarterly MDS, with an Assessment Reference Date (ARD) of 09/14/18, revealed a Basic Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Resident #42 was independent with bed mobility, transfers, walking, locomotion, dressing, and toileting. Resident #42 required limited assistance with one person physical assistance with personal hygiene and bathing. Resident #42 did not have any Range of Motion (ROM) impairments. Resident #42 usually made herself understood, and usually understood others.

CI MS # Based on interview, record review and policy review, the facility failed to ensure that the diet care plan was followed for one (1) of six (6) resident's reviewed, Resident #1. This was evidenced by, Resident #1 was care planned for a mechanical soft diet with pureed meat and thin liquids. Resident #1 was given a whole sausage dog on [DATE] by Certified Nursing Assistant (CNA) #1 which caused the resident to choke and subsequently expire on [DATE]. Findings include: Cross refer to F-365 for the facility's failure to ensure that physician's orders [REDACTED].#1 when she received a whole sausage dog instead of a pureed one which was ordered and care planned. Record review of Resident #1's [DATE] physician's orders [REDACTED]. Record review of Resident #1's Care Plan dated [DATE] and the CNA's Daily Care Guide dated [DATE], revealed Resident #1 was care planned for a mechanical soft diet with pureed meat and thin liquids. Record review of the facility's Investigative Summary Report for [DATE], documented that Resident #1 was given a whole sausage by Certified Nursing Assistant (CNA) #1 during a "cookout" and the resident was supposed to have pureed food. The report documented that Resident #1 choked on a piece of sausage causing her death. Record review of an ambulance report dated [DATE], documented that a large type hot dog that was approximately two (2) inches was removed from Resident #1's trachea with Magill forceps and a second piece approximately one (1) inch was removed further down the trachea. Record review of a Discharge Summary, dated [DATE], documented that Resident #1 had a discharge [DIAGNOSES REDACTED]. Interview on [DATE] at 4:29 p.m. with the Director of Nursing (DON), revealed that Resident #1's physician's diet orders and care plan had not been followed on [DATE], that Resident #1's diet order and care plan was for mechanical soft pureed meats. The facility's policy entitled "Interdisciplinary Care Plan", with a revised date of February 2012, revealed that care will be provided as planned. A Daily Care Guide will be provided to the CNA responsible for the resident's care. The facility submitted an acceptable Allegation of Compliance related to the Immediate Jeopardy (IJ) on [DATE] at 2:45 p.m. A review of the facility's Credible Allegation of Compliance: "This is the facility's Credible Allegation of Compliance (AOC) concerning an incident that occurred [DATE], when CNA #1 mistakenly gave Resident #1 a food item during a Therapeutic event that resulted in the choking death of Resident #1. On [DATE] at approximately 2:10 p.m., Resident #1 was given by CNA #1 a solid sausage dog during a Therapeutic Programming Father's Day cookout in the dining room. Resident #1 was care planned for a mechanical soft, pureed meat diet by a physician's orders [REDACTED]. At approximately 2:10 p.m. on [DATE], RN #1 was made aware by another resident at the table that something was wrong with Resident #1. RN #1 assessed that Resident #1 was becoming unresponsive because Resident #1 could not answer questions and cyanotic at the mouth. RN #1 made a visual check of Resident #1's oral cavity. When no visible food was identified, RN #1 performed the [MEDICATION NAME] Maneuver without success, LPN #1 performed the [MEDICATION NAME] Maneuver without results. Resident #1 was lowered to the floor and abdominal thrusts were initiated by LPN #1. At 2:12 p.m., RN #1 called [DATE]. Cardio [MEDICAL CONDITION] Resuscitation (CPR) was started by RN #2 because she could not get a pulse on Resident #1. This was continued by LPN #1 and RN #2 along with several other staff members who were taking turns. Staff who performed CPR included LPN #2, RN #3, LPN #3, LPN #4, CNA #2 and CNA #3. Staff continued CPR until the ambulance service arrived on the scene at 2:25 p.m. Paramedics from ambulance service were able to remove a piece of meat that was lodged in Resident #1's throat with a tongue device prior to Resident #1 being intubated by the paramedics. Staff continued to assist paramedics with CPR until Resident #1 was on the stretcher and in the ambulance. LPN #1 accompanied ambulance staff to continue CPR en route to the hospital for further evaluation. Resident #1 was placed on a ventilator at the hospital. On [DATE] at 9:15 a.m., staff from the hospital called facility staff to inform them that Resident #1 had expired. CNA #1 did not have direct patient care for the remainder of [DATE]. CNA #1 was placed on Administrative Leave [DATE] due to serving the incorrect food per physician's diet order to Resident #1. The facility identified a problem on [DATE], that a CNA from one hall would not be familiar with the physician's orders [REDACTED]. The facility initiated a protocol to ensure the correct food form gets to residents as ordered and staff, regardless of what area they work, are able to determine what each resident can eat or drink. RN Educator started in-services [DATE] at approximately 4:00 p.m. with all staff present at the facility. The in-services covered changes that were made to ensure that food and beverages were given to each resident in accordance to physician's orders [REDACTED]. In-service included: ? The system by which Therapeutic Programming staff identified resident diets was changed from the Tray Service Meal Notes list to an Alphabetized Physicians Orders List of diets produced by the MDS Nursing Staff daily ? This physician's orders [REDACTED]. ? Therapeutic Programming staff will receive a copy of the Physicians Orders list between the hours of 8:00am and 10:00am Monday through Friday. ? The MDS Nurse will provide Therapeutic Programming with a physician's orders [REDACTED]. The charge nurse on each station will be responsible for updating any diet changes or new diets orders from 4 p.m. on Friday until 8 a.m. on Monday on the Physicians' Orders List. Anytime the resident's diet is changed, the Physicians' Orders List will be updated either by MDS or the charge nurse. ? The MDS Nurse will also provide a copy of the Physicians Orders list to the Nurse's Station on both Dogwood and Wisteria halls. ? A copy of the Physicians Orders list will be provided to the Nursing Facility Administrator and kept on file in the Administrator's Office for 90 days. ? This Physicians Orders list will always be utilized in the dining room or in any location where food or beverage is served to ensure proper food items are served. ? This Physicians Orders list will always be utilized during "Special Events". ? Staff providing food and beverage will identify the resident name, diet, and any special considerations including allergies [REDACTED]. ? Staff assisting with meal service will be knowledgeable with special/therapeutic diet considerations which are part of the Physicians Orders List. This includes identification of food consistency required by any listed diet. ? If any discrepancy is noted between the Food Service Meal Ticket and the Physicians Orders List, staff is to get clarification of the Physicians' Order before serving the meal. ? If the Physicians Orders List 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 list is available and checked for reference. ? If a resident requests additional food/beverage items during meals, Staff must clarify with the dietary department to ensure the resident may have the food and beverage items. On [DATE], at approximately 7 p.m., RN Educator initiated an in-service covering the procedures that ensure that physician's orders [REDACTED]. No staff will be able to return to work until they have completed all in-services. Any newly hired employee will be trained on the procedure before they are allowed to work. A Quality Assurance (QA) Committee meeting was held on [DATE] at 8:05 a.m. to discuss the incident of [DATE] concerning Resident #1 and the actions that were taken as the before mentioned changes/in-services. Those attending were the Administrator, the Director of Nursing, the Risk Manager, the Director of QA/MDS/Risk Management/Infection Control, the Medical Director and the QA Nurse. No other recommendations were made at this time at [DATE] at 8:05 a.m. On [DATE] at 2:45 p.m., Director of QA/MDS/Risk Management/Infection Control initiated a review of all 84 resident Physicians Orders to ensure that they match the meal tickets and the Care Plan. Those who reviewed the Physicians Orders to ensure that they match the meal tickets and Care Plan were MDS RN #1, MDS RN #2, MDS RN #3, Quality Assurance RN, Risk Manager RN and Director of QA/MDS/Risk Management/Infection Control. On [DATE] at 10:00 a.m., the Quality Assurance RN initiated monitoring Therapeutic snacks and one meal service per day to ensure the Physician order [REDACTED]. Any concerns or non-compliance will be reported to QA as needed." The surveyor validated the corrective actions taken by the facility as follows: A review of in-service records and sign-in sheets validated in-services held beginning on [DATE] and interviews with staff members further validated their attendance and content of the meeting which included a protocol to ensure that food and beverages were given to each resident according to physician's orders [REDACTED]. A review of in-service records and sign-in sheets validated in-services beginning on [DATE] and interviews will staff members validated their attendance and content of the meeting which included following physician's orders [REDACTED]. Information that was given to employees at in-services beginning [DATE] and [DATE] was reviewed for validation of in-service content. Observation of the Physician order [REDACTED]. Review of the QA sign in sheet and interview with the Medical Director on [DATE] at 8:40 a.m. validated that a QA meeting was held on [DATE] with no further recommendations for the incident with Resident #1. Observation on [DATE] during 10:00 a.m. and 2:00 p.m. activity snack time and lunch/supper meal validated that staff utilized the Physician order [REDACTED]. Observation on [DATE] during 10:00 a.m. and 2:00 p.m. activity snack time and lunch/supper meal and interview with the RN QA Nurse on [DATE] at 10:05 a.m. validated that the RN QA Nurse was monitoring the food/beverage delivery to residents during snacks/meal service. Review of the monitoring sheet from [DATE]-[DATE] validated that staff was following proper procedures for verification of diet orders and diets. Observation and review of the Physician order [REDACTED].#A. Random review of the Physician order [REDACTED].#3, #4, #5, #6, Unsampled Resident #A and #B. Interview with the Director of QA/MDS/Risk Management/Infection Control, MDS RN #1, MDS RN #2, and MDS RN #3 on [DATE] at 4:42 p.m. and review of documentation on a current census report validated that the facility had reviewed all 84 resident physician's orders [REDACTED]. Interview with CNA #1 on [DATE] at 5:00 p.m. and review of CNA #1's personnel file validated that she was placed on and still remained on administrative leave as of [DATE]. Interview with CNAs on both Dogwood and Wisteria Hall on [DATE] at 3:45 p.m., 3:50 p.m., 4:15 p.m. and 4:25 p.m. validated that they had been in-serviced and was unable to serve any resident food unless the Physician order [REDACTED]. The CNAs verified that any discrepancy would be clarified prior to serving the resident and that care plans were to be followed. Interview with RNs/LPNs on [DATE] at 4:35 p.m. revealed that they had attended inservices which included following physician's orders [REDACTED]. Interview with Therapeutic Programming staff on [DATE] at 4:10 p.m. validated that the Physician order [REDACTED]. Interview with the DON on [DATE] at 4:29 p.m. validated that staff was inserviced on [DATE] regarding the change in protocol for utilizing the Physician order [REDACTED]. An acceptable Allegation of compliance was received on [DATE] which alleged removal of Immediate Jeopardy on [DATE]. The State Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to "D" 42 CFR 483.20 Resident Assessment (F-282), while the facility monitors the effectiveness of systemic changes and quality assurance activities.

CI MS # Based on interview, record review and policy review, the facility failed to ensure that the necessary care and services as per physician's orders [REDACTED].#1. Resident #1 had orders for a mechanical soft diet with pureed meat and was served a whole sausage dog on [DATE] which resulted in the resident's death after choking on the whole sausage. Findings include: Cross refer to F-365 for the facility's failure to ensure that residents received the appropriate food items per physician's orders [REDACTED].#1 on [DATE]. Review of the [DATE] physician's orders [REDACTED]. Record review of the facility's Investigative Summary Report for [DATE], stated that Resident #1 was given a whole sausage by Certified Nursing Assistant (CNA) #1 during a "cookout" and the resident was supposed to have pureed food. The report documented that Resident #1 choked on a piece of sausage causing her death. Record review of an ambulance report dated [DATE], stated that a large type hot dog that was approximately two (2) inches was removed from Resident #1's trachea with Magill forceps and a second piece approximately one (1) inch was removed further down the trachea. Record review of a Discharge Summary, dated [DATE], stated that Resident #1 had a discharge [DIAGNOSES REDACTED]. Interview on [DATE] at 4:29 p.m. with the Director of Nursing (DON), stated that Resident #1's physician's diet orders had not been followed on [DATE], that Resident #1's diet order was for mechanical soft pureed meats. Interview on [DATE] at 10:35 a.m. with the RN Risk Management Director, stated that following the physician's orders [REDACTED]. The facility's policy entitled "Standard Nursing Practice", with a revised date of February 2012, revealed that the purpose of this policy is to ensure staff adheres to acceptable practice standards. Nursing personnel will follow established standard nursing practice procedures. This Standard Nursing Practice policy consisted of approximately ten (10) lines, which was approximately a quarter of a page. The policy had an area noted: 1. Policy, 2. Purpose, and 3. Procedure with a statement under each area. The facility submitted an acceptable Allegation of Compliance related to the Immediate Jeopardy (IJ) on [DATE] at 2:45 p.m. A review of the facility's Credible Allegation of Compliance: "This is the facility's Credible Allegation of Compliance (AOC) concerning an incident that occurred [DATE], when CNA #1 mistakenly gave Resident #1 a food item during a Therapeutic event that resulted in the choking death of Resident #1. On [DATE] at approximately 2:10 p.m., Resident #1 was given by CNA #1 a solid sausage dog during a Therapeutic Programming Father's Day cookout in the dining room. Resident #1 was care planned for a mechanical soft, pureed meat diet by a physician's orders [REDACTED]. At approximately 2:10 p.m. on [DATE], RN #1 was made aware by another resident at the table that something was wrong with Resident #1. RN #1 assessed that Resident #1 was becoming unresponsive because Resident #1 could not answer questions and cyanotic at the mouth. RN #1 made a visual check of Resident #1's oral cavity. When no visible food was identified, RN #1 performed the [MEDICATION NAME] Maneuver without success, LPN #1 performed the [MEDICATION NAME] Maneuver without results. Resident #1 was lowered to the floor and abdominal thrusts were initiated by LPN #1. At 2:12 p.m., RN #1 called [DATE]. Cardio [MEDICAL CONDITION] Resuscitation (CPR) was started by RN #2 because she could not get a pulse on Resident #1. This was continued by LPN #1 and RN #2 along with several other staff members who were taking turns. Staff who performed CPR included LPN #2, RN #3, LPN #3, LPN #4, CNA #2 and CNA #3. Staff continued CPR until the ambulance service arrived on the scene at 2:25 p.m. Paramedics from ambulance service were able to remove a piece of meat that was lodged in Resident #1's throat with a tongue device prior to Resident #1 being intubated by the paramedics. Staff continued to assist paramedics with CPR until Resident #1 was on the stretcher and in the ambulance. LPN #1 accompanied ambulance staff to continue CPR en route to the hospital for further evaluation. Resident #1 was placed on a ventilator at the hospital. On [DATE] at 9:15 a.m., staff from the hospital called facility staff to inform them that Resident #1 had expired. CNA #1 did not have direct patient care for the remainder of [DATE]. CNA #1 was placed on Administrative Leave [DATE] due to serving the incorrect food per physician's diet order to Resident #1. The facility identified a problem on [DATE], that a CNA from one hall would not be familiar with the physician's orders [REDACTED]. The facility initiated a protocol to ensure the correct food form gets to residents as ordered and staff, regardless of what area they work, are able to determine what each resident can eat or drink. RN Educator started in-services [DATE] at approximately 4:00 p.m. with all staff present at the facility. The in-services covered changes that were made to ensure that food and beverages were given to each resident in accordance to physician's orders [REDACTED]. In-service included: ? The system by which Therapeutic Programming staff identified resident diets was changed from the Tray Service Meal Notes list to an Alphabetized Physicians Orders List of diets produced by the MDS Nursing Staff daily ? This physician's orders [REDACTED]. ? Therapeutic Programming staff will receive a copy of the Physicians Orders list between the hours of 8:00am and 10:00am Monday through Friday. ? The MDS Nurse will provide Therapeutic Programming with a physician's orders [REDACTED]. The charge nurse on each station will be responsible for updating any diet changes or new diets orders from 4 p.m. on Friday until 8 a.m. on Monday on the Physicians' Orders List. Anytime the resident's diet is changed, the Physicians' Orders List will be updated either by MDS or the charge nurse. ? The MDS Nurse will also provide a copy of the Physicians Orders list to the Nurse's Station on both Dogwood and Wisteria halls. ? A copy of the Physicians Orders list will be provided to the Nursing Facility Administrator and kept on file in the Administrator's Office for 90 days. ? This Physicians Orders list will always be utilized in the dining room or in any location where food or beverage is served to ensure proper food items are served. ? This Physicians Orders list will always be utilized during "Special Events". ? Staff providing food and beverage will identify the resident name, diet, and any special considerations including allergies [REDACTED]. ? Staff assisting with meal service will be knowledgeable with special/therapeutic diet considerations which are part of the Physicians Orders List. This includes identification of food consistency required by any listed diet. ? If any discrepancy is noted between the Food Service Meal Ticket and the Physicians Orders List, staff is to get clarification of the Physicians' Order before serving the meal. ? If the Physicians Orders List 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 list is available and checked for reference. ? If a resident requests additional food/beverage items during meals, Staff must clarify with the dietary department to ensure the resident may have the food and beverage items. On [DATE], at approximately 7 p.m., RN Educator initiated an in-service covering the procedures that ensure that physician's orders [REDACTED]. No staff will be able to return to work until they have completed all in-services. Any newly hired employee will be trained on the procedure before they are allowed to work. A Quality Assurance (QA) Committee meeting was held on [DATE] at 8:05 a.m. to discuss the incident of [DATE] concerning Resident #1 and the actions that were taken as the before mentioned changes/in-services. Those attending were the Administrator, the Director of Nursing, the Risk Manager, the Director of QA/MDS/Risk Management/Infection Control, the Medical Director and the QA Nurse. No other recommendations were made at this time at [DATE] at 8:05 a.m. On [DATE] at 2:45 p.m., Director of QA/MDS/Risk Management/Infection Control initiated a review of all 84 resident Physicians Orders to ensure that they match the meal tickets and the Care Plan. Those who reviewed the Physicians Orders to ensure that they match the meal tickets and Care Plan were MDS RN #1, MDS RN #2, MDS RN #3, Quality Assurance RN, Risk Manager RN and Director of QA/MDS/Risk Management/Infection Control. On [DATE] at 10:00 a.m., the Quality Assurance RN initiated monitoring Therapeutic snacks and one meal service per day to ensure the Physician order [REDACTED]. Any concerns or non-compliance will be reported to QA as needed." The surveyor validated the corrective actions taken by the facility as follows: A review of in-service records and sign-in sheets validated in-services held beginning on [DATE] and interviews with staff members further validated their attendance and content of the meeting which included a protocol to ensure that food and beverages were given to each resident according to physician's orders [REDACTED]. A review of in-service records and sign-in sheets validated in-services beginning on [DATE] and interviews will staff members validated their attendance and content of the meeting which included following physician's orders [REDACTED]. Information that was given to employees at in-services beginning [DATE] and [DATE] was reviewed for validation of in-service content. Observation of the Physician order [REDACTED]. Review of the QA sign in sheet and interview with the Medical Director on [DATE] at 8:40 a.m. validated that a QA meeting was held on [DATE] with no further recommendations for the incident with Resident #1. Observation on [DATE] during 10:00 a.m. and 2:00 p.m. activity snack time and lunch/supper meal validated that staff utilized the Physician order [REDACTED]. Observation on [DATE] during 10:00 a.m. and 2:00 p.m. activity snack time and lunch/supper meal and interview with the RN QA Nurse on [DATE] at 10:05 a.m. validated that the RN QA Nurse was monitoring the food/beverage delivery to residents during snacks/meal service. Review of the monitoring sheet from [DATE]-[DATE] validated that staff was following proper procedures for verification of diet orders and diets. Observation and review of the Physician order [REDACTED].#A. Random review of the Physician order [REDACTED].#3, #4, #5, #6, Unsampled Residents #A and #B. Interview with the Director of QA/MDS/Risk Management/Infection Control, MDS RN #1, MDS RN #2, and MDS RN #3 on [DATE] at 4:42 p.m. and review of documentation on a current census report validated that the facility had reviewed all 84 resident physician's orders [REDACTED]. Interview with CNA #1 on [DATE] at 5:00 p.m. and review of CNA #1's personnel file validated that she was placed on and still remained on administrative leave as of [DATE]. Interview with CNAs on both Dogwood and Wisteria Hall on [DATE] at 3:45 p.m., 3:50 p.m., 4:15 p.m. and 4:25 p.m. validated that they had been in-serviced and was unable to serve any resident food unless the Physician order [REDACTED]. The CNAs verified that any discrepancy would be clarified prior to serving the resident and that care plans were to be followed. Interview with RNs/LPNs on [DATE] at 4:35 p.m. revealed that they had attended inservices which included following physician's orders [REDACTED]. Interview with Therapeutic Programming staff on [DATE] at 4:10 p.m. validated that the Physician order [REDACTED]. Interview with the DON on [DATE] at 4:29 p.m. validated that staff was inserviced on [DATE] regarding the change in protocol for utilizing the Physician order [REDACTED]. An acceptable Allegation of compliance was received on [DATE] which alleged removal of Immediate Jeopardy on [DATE]. The State Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to "D" 42 CFR 483.20 Resident Assessment (F-309), while the facility monitors the effectiveness of systemic changes and quality assurance activities.

CI MS # Based on interview, record review and policy review, the facility failed to ensure that one (1) of six (6) residents reviewed, Resident #1, was provided the proper food form related to the meat consistency as ordered and care planned during a facility cook-out which resulted in Resident #1 choking on 6/15/13. Resident #1 was transported to the hospital, admitted to the Critical Care Unit and expired on 6/16/13 with a [DIAGNOSES REDACTED]. Certified Nursing Assistant (CNA) #1, who was not knowledgeable of Resident #1's diet orders, mistakenly gave Resident #1 a solid sausage dog and the resident was care planned and had physician's orders [REDACTED]. Findings include: Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/2/13, revealed that she was cognitively intact with a Brief interview for Mental Status (BIMS) score of 14. (13-15 is indicative of a cognitively intact resident). Review of Resident #1's June 2013 printed physician's orders [REDACTED]. Review of Resident #1's care plan dated 3/12/13 and the CNA's Daily Care Guide dated 6/4/13, revealed that Resident #1 was care planned for a mechanical soft diet with pureed meats and thin liquids. Review of a dietary Medical Nutrition Therapy LTC Assessment for Resident #1 dated 3/7/13 and a follow-up assessment on 5/31/13, revealed that Resident #1 had a chewing and swallowing problem with signs and symptoms of choking on various foods per Speech Therapy and nursing reports. Resident #1 was to continue her diet of mechanical soft/pureed meats. Review of Nurse's Notes dated 6/15/13 at 1410 (2:10 p.m.),revealed that Resident #1 was in the dining room and another resident reported to RN #1 that Resident #1 needed help. RN #1 asked Resident #1 if she was alright and the resident could not respond. Resident #1's mouth was open and nothing was observed in the resident's mouth at that time. Resident was not able to cough and RN #1 attempted the [MEDICATION NAME] maneuver but was not able due to not being able to put her arms around the resident in the wheelchair. LPN #1 proceeded to do the [MEDICATION NAME] maneuver until Resident #1 was nonresponsive. Resident #1 was positioned on the floor per LPN #1, RN #1 and RN #2 with abdominal thrusts per LPN #1. Nothing was seen in Resident #1's mouth. Not able to obtain a brachial pulse and CPR (Cardio-Pulmonary Resuscitation) was initiated with mouth-to-mouth and chest compressions. Resident #1's lips were cyanotic. Staff started breaths with ambu bag hooked to the oxygen concentrator and continued chest compressions. At 1412 (2:12 p.m.) RN #1 notified Metro (ambulance) and the Nurse Practitioner, and the Administrator who was already present. CPR was continued. At 1425 (2:45 p.m.) Metro arrived and staff continued CPR. Metro staff took over and was able to remove a piece of meat lodged in resident's throat with tongs prior to intubation. CPR was continued until Resident #1 was on the stretcher and taken by Metro. Nurse's Notes dated 6/16/13 at 9:15 a.m. revealed that someone from the hospital notified LPN #1 that Resident #1 had coded again and had not survived. Review of a Physician's progress note dated 6/17/13 at 1400 (2:00 p.m.) revealed that Resident #1 had expired at the hospital on [DATE] after [MEDICAL CONDITION] and did not recover. She had aspirated on a piece of sausage on Saturday (6/15/13) and staff performed the [MEDICATION NAME] maneuver and abdominal thrusts but did not dislodge the [MEDICATION NAME]. EMS arrived and was able to dislodge and resident was subsequently intubated and taken to the hospital where she expired on 6/16/13. Review of the Ambulance report dated 6/15/13 revealed that dispatch time was 14:14 (2:14 p.m.) and arrival time was 14:24 (2:45 p.m.) for a [MEDICAL CONDITION] post choking of Resident #1. Documentation revealed that a large type hot dog approximately 2 inches was removed from the resident's trachea with Magill forceps and a second piece of hot dog approximately 1 inch was removed slightly further down trachea. Resident's pupils were fixed and dilated, skin was warm and dry, no extremity movement, no pulse and absent breath sounds. Review of Resident #1's hospital record dated 6/15/13 revealed that she arrived at 14:55 (2:55 p.m.) via ambulance. Resident #1 arrived with no pulse and no spontaneous respirations with full code in progress and by history resident choked on a hot dog. Resident #1 was admitted to Critical Care Unit. Review of the hospital History and Physical for Resident #1 dated 6/15/13 revealed that Resident #1 was status [REDACTED]. Review of a Discharge Summary for Resident #1 dated 6/16/13 revealed that Resident #1 had become unresponsive while eating and the paramedics were called. Resuscitative measures were initiated when they arrived and apparently a large piece of hot dog was removed. Resident #1 regained a pulse and pressure about 10 minutes into treatment at the emergency room . The patient never regained consciousness and remained hypotensive. This morning (6/16/13), the patient had been coded and was pronounced dead. The discharge [DIAGNOSES REDACTED]. Review of an Investigative Summary Report of the event on 6/15/13 for Resident #1, revealed that on 6/15/13 at approximately 2:10 p.m., Resident #1 choked on a piece of sausage causing her death. The investigation revealed that during a "cookout", CNA # 1 had mistakenly given Resident #1 a whole sausage and the resident was supposed to receive pureed food. Per the Administrator, during special events on the unit or "cookouts" no meal tickets are provided explaining what diet the residents are on. Per RN Educator there was a "tray service meal note" that was provided monthly to Activity Personnel only and that there was no policy, procedure, or protocol in place describing implementation of the distribution of meals during special events or cookouts. Interview with the Administrator on 6/19/13 at 5:25 p.m. revealed that each month there was a main activity event on the weekend and on 6/15/13 there was a Father's Day cook out with grilled sausage dogs. The Administrator stated that there was a lot of excitement from the residents about the cookout and CNA #1, who worked a different hall from where Resident #1 lived, gave Resident #1 a regular sausage dog and not the pureed that she was supposed to have. The Administrator stated that the activity staff had a list of resident diets and they worked with the residents daily but the Certified Nursing Assistants (CNAs) were assisting. The Administrator stated that one of the staff came and got him and said that Resident #1 was choking and when he got to the scene Resident #1 was on the floor and staff were performing abdominal thrusts. The Administrator stated that the ambulance crew arrived and used forceps to retrieve a piece of hot dog from Resident #1's throat, resident was taken to the hospital and admitted to the Critical Care Unit where she expired the next day. The Administrator stated that CNA #1 was placed on administrative leave Monday 6/17/13 after taking statements and discovering that she had been the one to give Resident #1 the hot dog. Interview with RN #1 on 6/20/13 at 12:55 p.m. revealed that she had come to the dining room on 6/15/13 to get some food for a couple of residents on the hall. RN #1 stated that a resident at Resident #1's table said "she needs you". RN #1 stated that Resident #1's mouth was open and she wasn't speaking. RN #1 asked the resident if she was okay or choking but the resident didn't respond. RN #1 stated that Resident #1 was bluish around the mouth and not able to breath. RN #1 stated that she attempted the [MEDICATION NAME] Maneuver without success along with LPN #1. RN #1 stated that she couldn't see anything in Resident #1's mouth and the resident was laid on the floor and LPN #1 performed abdominal thrusts without success. RN #1 stated that RN #2 was on the scene so she left and notified the ambulance and upon return staff was performing CPR. RN #1 stated that she saw a solid piece of hot dog laying on the floor next to Resident #1 that was approximately one and one half inches long and not chewed up. RN #1 stated that Resident #1 was supposed to have pureed meats and at the time she wasn't sure had she'd gotten the whole hot dog but later found out that CNA #1 had given it to her by mistake. RN #1 stated that Resident #1 could have told staff that she wasn't supposed to have the whole meat. Interview with RN #2 on 6/20/13 at 8:45 a.m. revealed that she had been at the cookout (6/15/13) when she heard someone say "she's choking", and she looked to see LPN #1 performing the [MEDICATION NAME] Maneuver on Resident #1. RN #2 stated that when they laid Resident #1 on the floor to do abdominal thrusts that she felt no pulse so CPR was initiated. RN #2 stated that she was not aware that Resident #1 had been given a whole sausage dog at the time she was choking but when EMS arrived they retrieved a piece of whole sausage from her mouth. RN #2 stated that this was the 2:00 p.m. snack/activity special event and not a regular meal, lunch had already been served. RN #2 stated that Resident #1 should have been given pureed meats and not whole meats. RN #2 stated that now there was a physician's orders [REDACTED]. RN #2 stated that she was not aware of a list of diets for activities prior. Interview with LPN #1 on 6/19/13 at 6:15 p.m. revealed that Resident #1 was in the wheelchair unresponsive and that he had performed the [MEDICATION NAME] Maneuver without success, the resident was laid in the floor and abdominal thrusts were performed. LPN #1 stated that he didn't see anything in the resident's mouth but staff had said that she was choking. LPN #1 stated that RN #2 initiated Cardiopulmonary Resuscitation (CPR) when there was no pulse for Resident #1 and staff took turns doing chest compressions. LPN #1 stated that when the ambulance arrived a piece of solid hot dog was retrieved from Resident #1's throat. LPN #1 stated that Resident #1 was still unresponsive and that CPR was continued while in the ambulance to the hospital. LPN #1 stated that Resident #1 expired the next day. LPN #1 stated that Resident #1 was supposed to have pureed meats. LPN #1 stated that the procedure now was to have the physician's orders [REDACTED]. Interview with LPN #2 on 6/20/13 at 9:50 a.m. revealed that she walked into the Dining Room around 2:00 p.m. or so and saw LPN #1 performing the [MEDICATION NAME] on Resident #1. LPN #2 stated that Resident #1 was unresponsive and CPR was initiated and that she had assisted with alternating chest compressions but the resident never responded. LPN #2 stated that a piece of solid, not chewed up, piece of hot dog/sausage was gotten out of Resident #1's mouth after the ambulance arrived. LPN #2 stated that Resident #1 was on a mechanical soft diet with pureed meats. LPN #2 stated that physician's orders [REDACTED]. LPN #2 stated that staff usually went by the meal ticket, but this was an activity and not a meal and usually the activity staff serve food/drink at those events. Interview with CNA #1 on 6/20/13 at 5:00 p.m. revealed that she worked on Wisteria Hall and had worked approximately four (4) years. CNA #1 stated that the sausage dogs had been wrapped up outside and brought to the dining room in a box around 2:00 p.m. and the activity girls were putting the dogs in a plastic plate. CNA #1 stated that the residents were already present at the tables and very excited. CNA #1 stated that they were raising their hands for the sausage dogs and she had given out the sausage dogs to resident's at Resident #1's table, including Resident #1. CNA #1 stated that Resident #1 unwrapped the sausage dog herself and began to bite it. CNA #1 stated that she was unaware that Resident #1 couldn't have the sausage dog because she lived on Dogwood Hall and had not worked with her. CNA #1 stated that she thought that Resident #1 would have said that she wasn't supposed to eat the whole thing or something like "that's not the right one for me" if she couldn't have it. CNA #1 stated that there had been no diet lists available, that it was a recreational event, not a meal where the meal ticket would have been available. CNA #1 stated that maybe five (5) minutes after she'd given Resident #1 the sausage dog she heard a commotion at Resident #1's table and they were "working with her". CNA #1 stated that the ambulance arrived and pulled a piece of hot dog out of her mouth that was about one to one and one half inches of solid meat. CNA #1 stated that the Investigator came to the facility and took statements and the RN Educator came and talked to everyone about the procedure change that included making sure there was a list of the resident's diets and that nothing would be served unless the list was checked or ask a nurse if not sure. CNA #1 stated that she had been put on administrative leave and had not been allowed to return to work as of yet. CNA #1 stated that she would not have given Resident #1 the whole sausage dog if she had known that she wasn't supposed to have it. Interview with CNA #3 on 6/19/13 at 7:35 p.m. revealed that he had talked to Resident #1 in the dining room and asked her if she was enjoying (the food) and she had said that it was good. CNA #3 stated that Resident #1 had a small piece of bread left and no hot dog and was in no distress. CNA #3 stated three (3) to four (4) minutes later he heard someone say "she's choking" and saw nurses run to Resident #1. CNA #3 stated that he assisted with chest compressions during CPR. CNA #3 stated that in-service began that evening by the RN Educator to make sure that staff gave residents what they were supposed to have to eat; a sheet would be put out with the diets and staff was not to serve anything until the sheet was there and checked to make sure it was right and if there was any discrepancy we were to check with the nurse/dietary. CNA #3 stated that he did not assist activity staff with serving and was not aware of a diet list for activities, but there were meal tickets for meal times. Interview with CNA #4 on 6/19/13 at 6:50 p.m. revealed that she was not involved in passing out sausage dogs (6/15/13) but had come to get one herself. CNA #4 stated that she heard someone say "she's choking" and saw RN #1 trying to do the [MEDICATION NAME] Maneuver on Resident #1. CNA #4 stated that Resident #1's lips were blue and the resident was not responding. CNA #4 stated that Resident #1 was usually alert and oriented. CNA #4 stated that the ambulance crew pulled out a solid piece of hot dog and Resident #1 was supposed to have pureed meat. CNA #4 stated that CNAs should follow the Care Guide for resident care and diet. Interview with Therapeutic Programming Assistant, CNA #5, on 6/20/13 at 10:10 a.m. and again on 6/21/13 at 9:00 a.m. revealed that she had been in the kitchen getting some sausage meat pureed (6/15/13) and when she came into the dining room she saw staff working with Resident #1. CNA #5 stated that she was not aware at that time that Resident #1 had been served regular meat. CNA #5 stated that the use of the meal notes was in place at that time for Therapeutic Programming staff and in the dining room on a clip board. CNA #5 stated that the CNAs from the halls helped serve (sausage dogs) and the CNAs were supposed to know their residents from each hall. CNA #5 stated that Resident #1 was on her caseload but that she had not served residents that day; had only assisted with preparation of the food she wasn't aware who gave Resident #1 the whole sausage. Interview with the Medical Director on 6/20/13 at 8:40 a.m. revealed that he had been informed after the incident about Resident #1 choking on a piece of sausage, resuscitative efforts performed and that she had expired at the hospital. The Medical Director stated that orders and care plans should always be followed and a system to identify residents and their diets. Interview with the RN Investigator for campus investigative services on 6/21/13 at 12:20 p.m. revealed that he had received statements from the staff on 6/15/13 about Resident #1's choking incident. The RN Investigator stated that there was a system's failure for not having a diet list available to CNA staff for serving of cookout items. The RN Investigator stated that his investigation had revealed that there had been no policy or procedure in place describing implementation of the distribution of meals during special events/cookouts. The RN Investigator stated that the investigation had also revealed that there was a "tray service meal notes" for activity staff but the CNA who had given Resident #1 the hot dog was not aware of that list. Interview with the RN Educator on 6/21/13 at 1:05 p.m. revealed that she came to the facility 6/15/13 after Resident #1's choking incident. The RN Educator stated that activity staff was using a guide "tray service meal notes" that was provided to them monthly by the Dietician and it was used as a reference of giving residents food and beverages. The RN Educator stated that she had not been aware of that guide until 6/15/13. The RN Educator stated that to her knowledge, there had been no policy/protocol for staff distributing food during special events or cookouts until 6/15/13. The RN Educator stated that most of the activity staff were CNAs. Interview with the Registered Dietician (RD) on 6/21/13 at 2:25 p.m. revealed that he provided "tray service meal notes" to the activity staff monthly and had given in-services to the activity staff in December 2012 for diet appropriate snacks and gave to CNAs in orientation. The RD stated that the "tray service meal notes" were provided to activity because they use that list for activity events and special events where food is passed out. (The CNAs were given this inservice by the RD during orientation, as a part of the Activity Program. The training encompassed the diet meal process as a whole. The "tray service meal notes", came from the physician orders [REDACTED].) Interview with the Director of Nursing (DON) on 6/21/13 at 4:29 p.m. revealed that physician's orders [REDACTED]. The DON stated that Resident #1 had orders and care plan in place for mechanical soft pureed meats. Review of "Tray Service Meal Notes" dated 5/8/2013, which was used by Therapeutic Programming (recreational/activity) staff, revealed that Resident #1 was to receive a mechanical soft diet with pureed meats; divided plate; regular utensils, may use sippy cup with handle-no lid. There was no documented protocol or policy for when or who utilized the "Tray Service Meal Notes" list. (The "Tray Service Meal Notes" list were kept on a clip board in Activities, and the Activity Staff brought the list to wherever the activity was held.) Interview with the Director of Therapeutic Programming (DTP)on 6/21/13 at 8:25 a.m. revealed that the process that was used to identify resident's diets for therapeutic recreational activities or cook outs prior to 6/15/13 was for the Registered Dietician to create the "tray service meal notes" monthly for the Therapeutic Programming staff to use and it would be kept in the clipboard where the event was taking place. The DTP stated that the recreational staff had their own caseloads and knew their residents and their diets. The DTP stated that she was not aware of whether nursing staff knew about the "tray service meal notes" or not. (The CNAs do not normally serve during activities, but assisted when needed. During Activity observations, the Activity Staff served any food items and the nursing CNAs did not serve.) Review of the facility's policy entitled "Standard Nursing Practice", with a revised date of February 2012, revealed that the purpose of this policy is to ensure staff adheres to acceptable practice standards. Nursing personnel will follow established standard nursing practice procedures. This Standard Nursing Practice policy consisted of approximately ten (10) lines, which was approximately a quarter of a page. The policy had an area noted: 1. Policy, 2. Purpose, and 3. Procedure with a statement under each area. Review of the facility's policy entitled "Therapeutic Programming Services", with a revised date of February 2010, revealed no protocol for identifying residents prior to serving food or drink during recreational activities or events. Review of the facility's policy entitled "Interdisciplinary Care Plan", with a revised date of February 2012, revealed that care will be provided as planned. A Daily Care Guide will be provided to the CNA responsible for the resident's care. Interview with the RN Risk Management Director on 6/21/13 at 10:35 a.m. revealed that following the physician's orders [REDACTED]. Interview with the Administrator on 6/21/13 at 9:55 a.m. revealed that there had been no policy or protocol prior to 6/15/13 for serving snacks/food for therapeutic recreational events, had basically just gone by staff knowledge of the residents. The facility submitted an acceptable Allegation of Compliance related to the Immediate Jeopardy (IJ) on 6/21/13 at 2:45 p.m. A review of the facility's Credible Allegation of Compliance: "This is the facility's Credible Allegation of Compliance (AOC) concerning an incident that occurred June 15, 2013, when CNA #1 mistakenly gave Resident #1 a food form, related to the meat, during a Therapeutic event that resulted in the choking death of Resident #1. On 6/15/13 at approximately 2:10 p.m., Resident #1 was given by CNA #1 a solid sausage dog during a Therapeutic Programming Father's Day cookout in the dining room. Resident #1 was care planned for a mechanical soft, pureed meat diet by a physician's orders [REDACTED]. At approximately 2:10 p.m. on 6/15/2013, RN #1 was made aware by another resident at the table that something was wrong with Resident #1. RN #1 assessed that Resident #1 was becoming unresponsive because Resident #1 could not answer questions and cyanotic at the mouth. RN #1 made a visual check of Resident #1's oral cavity. When no visible food was identified, RN #1 performed the [MEDICATION NAME] Maneuver without success, LPN #1 performed the [MEDICATION NAME] Maneuver without results. Resident #1 was lowered to the floor and abdominal thrusts were initiated by LPN #1. At 2:12 p.m., RN #1 called 9-1-1. Cardio [MEDICAL CONDITION] Resuscitation (CPR) was started by RN #2 because she could not get a pulse on Resident #1. This was continued by LPN #1 and RN #2 along with several other staff members who were taking turns. Staff who performed CPR included LPN #2, RN #3, LPN #3, LPN #4, CNA #2 and CNA #3. Staff continued CPR until the ambulance service arrived on the scene at 2:25 p.m. Paramedics from ambulance service were able to remove a piece of meat that was lodged in Resident #1's throat with a tongue device prior to Resident #1 being intubated by the paramedics. Staff continued to assist paramedics with CPR until Resident #1 was on the stretcher and in the ambulance. LPN #1 accompanied ambulance staff to continue CPR en route to the hospital for further evaluation. Resident #1 was placed on a ventilator at the hospital. On 6/16/2013 at 9:15 a.m., staff from the hospital called facility staff to inform them that Resident #1 had expired. CNA #1 did not have direct patient care for the remainder of 6-15-13. CNA #1 was placed on Administrative Leave 6/17/2013 due to serving the incorrect food per physician's diet order to Resident #1. The facility identified a problem on June 15, 2013, that a CNA from one hall would not be familiar with the physician's orders [REDACTED]. The facility initiated a protocol to ensure the correct food form gets to residents as ordered and staff, regardless of what area they work, are able to determine what each resident can eat or drink. RN Educator started in-services 6/15/13 at approximately 4:00 p.m. with all staff present at the facility. The in-services covered changes that were made to ensure that food and beverages were given to each resident in accordance to physician's orders [REDACTED]. In-service included: ? The system by which Therapeutic Programming staff identified resident diets was changed from the Tray Service Meal Notes list to an Alphabetized Physicians Orders List of diets produced by the MDS Nursing Staff daily ? This physician's orders [REDACTED]. ? Therapeutic Programming staff will receive a copy of the Physicians Orders list between the hours of 8:00am and 10:00am Monday through Friday. ? The MDS Nurse will provide Therapeutic Programming with a physician's orders [REDACTED]. The charge nurse on each station will be responsible for updating any diet changes or new diets orders from 4 p.m. on Friday until 8 a.m. on Monday on the Physicians' Orders List. Anytime the resident's diet is changed, the Physicians' Orders List will be updated either by MDS or the charge nurse. ? The MDS Nurse will also provide a copy of the Physicians Orders list to the Nurse's Station on both Dogwood and Wisteria halls. ? A copy of the Physicians Orders list will be provided to the Nursing Facility Administrator and kept on file in the Administrator's Office for 90 days. ? This Physicians Orders list will always be utilized in the dining room or in any location where food or beverage is served to ensure proper food item (food form, related to the meat) are served. ? This Physicians Orders list will always be utilized during "Special Events". ? Staff providing food and beverage will identify the resident name, diet, and any special considerations including allergies [REDACTED]. ? Staff assisting with meal service will be knowledgeable with special/therapeutic diet considerations which are part of the Physicians Orders List. This includes identification of food consistency required by any listed diet. ? If any discrepancy is noted between the Food Service Meal Ticket and the Physicians Orders List, staff is to get clarification of the Physicians' Order before serving the meal. ? If the Physicians Orders List 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 list is available and checked for reference. ? If a resident requests additional food/beverage items during meals, Staff must clarify with the dietary department to ensure the resident may have the food and beverage items. On 6/19/13, at approximately 7 p.m., RN Educator initiated an in-service covering the procedures that ensure that physician's orders [REDACTED]. No staff will be able to return to work until they have completed all in-services. Any newly hired employee will be trained on the procedure before they are allowed to work. A Quality Assurance (QA) Committee meeting was held on 6/20/13 at 8:05 a.m. to discuss the incident of 6/15/13 concerning Resident #1 and the actions that were taken as the before mentioned changes/in-services. Those attending were the Administrator, the Director of Nursing, the Risk Manager, the Director of QA/MDS/Risk Management/Infection Control, the Medical Director and the QA Nurse. No other recommendations were made at this time at 6/20/13 at 8:05 a.m. On 6/20/13 at 2:45 p.m., Director of QA/MDS/Risk Management/Infection Control initiated a review of all 84 resident Physicians Orders to ensure that they match the meal tickets and the Care Plan. Those who reviewed the Physicians Orders to ensure that they match the meal tickets and Care Plan were MDS RN #1, MDS RN #2, MDS RN #3, Quality Assurance RN, Risk Manager RN and Director of QA/MDS/Risk Management/Infection Control. On 6/17/13 at 10:00 a.m., the Quality Assurance RN initiated monitoring Therapeutic snacks and one meal service per day to ensure the Physician order [REDACTED]. Any concerns or non-compliance will be reported to QA as needed." The surveyor validated the corrective actions taken by the facility as follows: A review of in-service records and sign-in sheets validated in-services held beginning on 6/15/13 and interviews with staff members further validated their attendance and content of the meeting which included a protocol to ensure that food and beverages were given to each resident according to physician's orders [REDACTED]. A review of in-service records and sign-in sheets validated in-services beginning on 6/19/13 and interviews will staff members validated their attendance and content of the meeting which included following physician's orders [REDACTED]. Information that was given to employees at in-services beginning 6/15/13 and 6/19/13 was reviewed for validation of in-service content. Observation of the Physician order [REDACTED]. Review of the QA sign in sheet and interview with the Medical Director on 6/20/13 at 8:40 a.m. validated that a QA meeting was held on 6/20/13 with no further recommendations for the incident with Resident #1. Observation on 6/21/13 during 10:00 a.m. and 2:00 p.m. activity snack time and lunch/supper meal validated that staff utilized the Physician order [REDACTED]. Observation on 6/21/13 during 10:00 a.m. and 2:00 p.m. activity snack time and lunch/supper meal and interview with the RN QA Nurse on 6/21/13 at 10:05 a.m. validated that the RN QA Nurse was monitoring the food/beverage delivery to residents during snacks/meal service. Review of the monitoring sheet from 6/18/13-6/21/13 validated that staff was following proper procedures for verification of diet orders and diets. Observation and review of the Physician order [REDACTED].#A. Random review of the Physician order [REDACTED].#3, #4, #5, #6, Unsampled Residents #A and #B. Interview with the Director of QA/MDS/Risk Management/Infection Control, MDS RN #1, MDS RN #2, and MDS RN #3 on 6/21/13 at 4:42 p.m. and review of documentation on a current census report validat