Chadwick Community Care Center

F 0628 Level of Harm - Minimal harm or potential for actual harm

severely cognitively impaired. Section A is coded for discharge not anticipated returning.A record review of

a typed statement on facility letterhead, undated and signed by the ED revealed Facility Acquired Discharges 2025 revealed Resident #1's (proper name) was the only name listed on this form.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chadwick Community Care Center

1900 Chadwick Drive Jackson, MS 39204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

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

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on observation, interview, record review, and facility policy review, the facility failed to implement the comprehensive care plan while providing perineal care for one (1) of two (2) residents observed for activities of daily living (ADL) care (Resident #4).Findings Include:A record review of the facility's Comprehensive Person-Centered Care Plans dated 1/25 revealed, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that will identify how the interdisciplinary team will provide care .A record review of Resident #4's Care Plan Report revealed a care plan with an initiation date of 10/2/24, Focus: (Proper name of Resident #4) is incontinent of bladder and bowel.Interventions. Incontinent checks/care every two (2) hours and as needed (PRN) x (times) 2-person assistance for total dependence . On 9/16/25 at 4:03 PM, during an observation of perineal care revealed CNA #1 provided perineal care without 2-person assistance as indicated on the care plan. On 09/16/25 at 4:16 PM, during an interview CNA #1 confirmed that he did not follow the care plan by using 2 persons for assistance with perineal care. On 09/16/25 at 5:08 PM, in an interview with Executive Director (ED) she stated, All CNAs should be able to provide care correctly.On 09/17/25 at 11:35 AM,

during an interview the Director of Nursing (DON) stated CNA#1 did not follow the care plan. She stated her expectation is for CNA's is to give good quality care and follow proper procedure for giving care.On 09/17/25 at 12:55 PM, during an interview Registered Nurse (RN) #2/Minimum Data Set (MDS) nurse stated she could not comment on what CNA #1 did or did not do, she was not there when he provided the care. She stated I can only say what the care plan says. The care plan states (2) people assistance with peri care. She stated the purpose of the care plan is to inform the CNAs of the care that is to be provided.

She stated the interventions indicate what the facility is doing for the residents. A record review of Resident #4's admission Record revealed the facility admitted the resident on9/27/18 with diagnoses including Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting the right side, Dysphasia following unspecified cerebrovascular disease, Aphasia following unspecified cerebrovascular disease, and Gastroesophageal Reflux Disease without esophagitis.A record review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was unable to complete the interview.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chadwick Community Care Center

1900 Chadwick Drive Jackson, MS 39204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

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

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Based on observation, interviews, record reviews and facility policy review the facility failed to provide perineal (peri-care) according to acceptable standards for one (1) of two (2) observations. Resident #4.Findings Include:A record review of the facility's Incontinent Care dated 07/12 revealed .10. Wash the resident's entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water, peri-wash or wipes. 11. When washing perineal area, wash the entire perineal, wash the entire area.On 09/16/25 at 4:03 PM, in an observation, Certified Nursing Assistant #1 (CNA) provided perineal care for Resident #4. CNA #1 placed the feeding pump on hold. He used three wipes and wiped front to back in the groin area on the right side. He then folded the wipe and wiped the same area again. He retrieved three (3) more wipes and wiped the left side front to back. He picked up the remaining wipes and wiped down the center of the vagina front to back one time. He turned resident on her left side to remove soiled brief. He placed soiled brief on the bed and placed a clean brief on the resident. CNA#1 did not separate the labia and wipe down each side and the center. He did not clean the rectal area. On 9/16/25 at 4:16 PM, during

an interview CNA #1 stated he had been trained to place the feeding pump on hold during care. He confirmed that he did not perform perineal care correctly. He stated he was nervous and forgot to follow proper procedure. CNA #1 acknowledged that his actions could cause Resident #4 to develop an infection.On 9/16/25 at 4:21 PM, during an interview Registered Nurse (RN) #2/ Unit Manager for the B Unit confirmed that CNA #1 did not provide care properly. She stated CNAs are not permitted to operate feeding pumps and that only nurses are authorized to do soOn 9/16/25 at 5:08 PM, during an interview the Executive Director (ED) stated that the State Agency (SA) should have picked anyone other than him to do peri care. She further stated all CNAs should be able to perform care correctly.On 9/17/25 at 11:35 AM,

during an interview the Director of Nursing (DON) stated CNA #1 should have informed the nurse so she could place the feeding pump on hold, as CNAs are not permitted to operate feeding pumps. The DON stated the pump could malfunction and cause harm to the resident if not handled properly. The DON further stated CNA #1 should have performed perineal care correctly, including applying clean gloves before providing care to the buttocks and skin folds. She stated CNA #1 did not provide care correctly. The DON stated her expectation is for CNAs to provide quality care and to follow proper procedures when giving care.A record review of Resident #4's admission Record revealed the facility admitted the resident on9/27/18 with diagnoses including Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting the right side, Dysphasia following unspecified cerebrovascular disease, Aphasia following unspecified cerebrovascular disease, and Gastroesophageal Reflux Disease without esophagitis.A record review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was unable to complete the interview.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chadwick Community Care Center

1900 Chadwick Drive Jackson, MS 39204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

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

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

gloves before performing perineal care on the buttocks area and skin folds. The DON stated EBP is implemented to protect residents and staff from infection, and CNA #1's actions placed the resident at risk for numerous infections, including urinary tract infection. She stated her expectation is that all CNAs provide quality care and follow proper procedures when providing resident care.On 9/18/25 at 8:12 AM, during a post-survey telephone interview, Registered Nurse (RN) #3, Infection Preventionist (IP), stated CNA #1 should have washed his hands before, during, and after providing care. She stated staff are trained in EBP and should wear gowns when providing care to high-risk residents. She stated CNA #1 should have followed infection control training. RN #3 stated she has conducted several in-service trainings on infection control and EBP, and that these trainings are conducted to prevent the spread of infection and are expected to be followed.A record review of Resident #4's admission Record revealed the facility admitted the resident on9/27/18 with diagnoses including Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting the right side, Dysphasia following unspecified cerebrovascular disease, Aphasia following unspecified cerebrovascular disease, and Gastroesophageal Reflux Disease without esophagitis.A record review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was unable to complete the interview.

Event ID:

Facility ID:

If continuation sheet