Jackson General Hospital

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 38626 Based on observation and interview, the facility failed to properly install and maintain equipment protected by the kitchen hood extinguishing system. The facility also failed to maintain the HVAC in accordance with NFPA (National Fire Protection Association) 101. Facility census 14. The findings include: a) Observation during documentation review on 08/10/26, between the hours of 2:00 p.m. and 4:00 p.m., revealed that there was no documentation available for review of the first half of 2026 for the range hood extinguishing system. b) Interview on 08/11/26 at approximately 10:30 a.m. with the Facilities Maintenance Director verified these findings. The findings were were also acknowledged by the Administrator at the exit interview on 08/11/26. c) During the facility document review conducted on 08/10/26 between the hours of 2:00 p.m. and 4:00 p.m. revealed that the Fire Dampers included in the new construction areas of the facility were not inspected one year after installation. d) Interview on 08/11/26 at approximately 10:30 a.m. with the Facilities Maintenance Director verified these findings. The findings were were also acknowledged by the Administrator at the exit interview on 08/11/26.”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 53453 Based on document review, medical review, and staff interview, the facility failed to follow their policy to ensure that all patients had an Activity Assessment completed by the activities coordinator within seven (7) days of admission to a swing bed status in three (3) out of thirty (30) medical records reviewed (patients, #1, #2, and #3), . This failure has the potential to adversely affect all patients admitted to the swing bed unit. Findings include: A policy titled: “Activities;” revised: 12/17/25; was reviewed, and stated: “The activities program will be directed by a qualified professional to coordinate and activity program by developing a monthly calendar which offers activities at hours convenient to the resident; reflects the schedules, choices, and rights of the resident; reflects cultural and religious interests of the of the swing bed resident population; and appeals to both men and women and all age groups in the activity program. Jackson General Hospital staff, as appropriate, will offer activities according to the activities calendar, as well as at additional times at the resident ’ s request. Documentation: The Activity Assessment in the electronic health record will be completed within 7 [seven] days of admission to swing bed. Participation in activities will be documented ...” A review of the medical records for swing bed patient #1, date of admission 08/03/26, with a diagnosis of cellulitis, was completed. There was no documented evidence of an Activity Assessment or participation in activities in the medical records. A review of the medical records for swing bed patient #2, date of admission 06/02/26, with a diagnosis of closed fracture of right calcanus, was completed. There was no documented evidence of an Activity Assessment or participation in activities from the activities calendar in the medical records. A review of the medical records for swing bed patient #3, date of admission 08/10/26, with a diagnosis of weakness/debility, was completed. There was no documented evidence of an Activity Assessment or participation in activities from the activities calendar in the medical records. A review of the July Activities Calendar revealed three (3) activities listed each day, and stated: “Activities are offered twice daily. Calendar represents suggested offerings, but the patient may pursue activity of choice at any time. If the patient declines, offer an alternative. The patient has the right to refuse.” An interview was conducted on 08/10/26 at 3:40 p.m. with staff #3, who confirmed that there was no activities director on the swing bed unit; and stated: “[Staff #5] prints off the activities calendar.” An interview was continued with staff #3 on 08/12/26 at 12:25 p.m. Staff #3 stated, “The patients get an activities calendar, but nobody actually does the activities with the patients. Only if they would ask...” An interview was conducted on 08/10/26 at 3:17 p.m. with staff #5, who stated: “I am not the activities coordinator. There is no particular person in charge of activities. I develop and print off the monthly activities calendar and order the activities from [on-line store], things like cards, games, and ring toss. Therapy gave me a general list of activities to order.” An interview was conducted on 08/11/26 at 2:44 p.m. with staff #2 who confirmed that there are no official activity directors on the swing bed unit. Staff #2 also confirmed that they were noncompliant with their policy, and that there were no Activity Assessments or any documented activities from the calendar in the medical records for patient #1, #2, and #3.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 38626 Based on observation and interview, the facility failed to properly install and maintain equipment protected by the kitchen hood extinguishing system. The deficient practice could affect staff, and no residents. Facility census is 14. The findings include: a) Observation during documentation review on 08/10/26, between the hours of 2:00 p.m. and 4:00 p.m., revealed that there was no documentation available for review of the first half of 2026 for the range hood extinguishing system. b) Interview on 08/11/26 at approximately 10:30 a.m. with the Facilities Maintenance Director verified these findings. The findings were were also acknowledged by the Administrator at the exit interview on 08/11/26.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 38626 Based on observation and staff interview, the facility failed to maintain the HVAC in accordance with NFPA (National Fire Protection Association) 101. Facility census 14. Findings include. a) During the facility document review conducted on 08/10/26 between the hours of 2:00 p.m. and 4:00 p.m. revealed that the Fire Dampers included in the new construction areas of the facility were not inspected one year after installation. b) Interview on 08/11/26 at approximately 10:30 a.m. with the Facilities Maintenance Director verified these findings. The findings were were also acknowledged by the Administrator at the exit interview on 08/11/26.”