Leakesville Rehabilitation and Nursing Center, Inc

In the surveyor’s words

From the most serious findings on record at Leakesville Rehabilitation and Nursing Center, Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF802May 9, 2024

  Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to have sufficient staff to assemble meal trays timely to prevent meals from being served late and cold for three (3) of four (4) days of survey. Findings include: Review of the facility's policy, Dietary Services-Staffing, revised 7/21/23, revealed, .The facility employs sufficient staff with the appropriate competencies in skill sets to carry out the functions of the Food and Nutrition Services, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment .Policy Explanation and Compliance Guidelines for Staffing .6. […]

• No harm, potential for more than minimal, widespreadF804May 9, 2024

  Based on observation, interviews, record review, and facility policy review, the facility failed to provide resident meals at an appetizing temperature for two (2) of two residents reviewed for food. Resident #32 and Resident #109. This had the potential to affect all residents who receive meals from the kitchen. Findings include: A record review of the facility's policy, Food and Nutrition Services, revised 10/2017, revealed . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs .Policy Interpretation and Implementation: . 7. […]

• No harm, potential for more than minimal, patternF657Feb 16, 2023

  Based on staff interview, record review, and facility policy review, the facility failed to revise the Comprehensive Care Plan for two (2) of three (3) sampled residents. Resident #1 and Resident #2. Findings include: A review of the facility's policy Care Plans - Comprehensive, revised May 2014, revealed, .Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team .maintains a comprehensive care plan for each resident .8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . Resident #1 A record review of the Face Sheet revealed the facility admitted Resident #1 on 7/21/21 and she had a current diagnosis of Pressure Ulcer of Right Heel, Unstageable. […]

• No harm, potential for more than minimal, patternF865Feb 16, 2023

  Based on interview and record review the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place in 12/2/22. The facility's continued failure during this and the previous survey in November 2022 on an annual recertification survey indicates a pattern of the facility's inability to sustain an effective QAPI Committee. Findings include: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Committee, dated July 2016, revealed, The facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program . The primary goals of the QAPI Committee are to: 1. […]

• No harm, potential for more than minimal, isolatedF558Nov 18, 2025

  Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the call light system accommodated the needs of a resident with contracted hands for one (1) of four (4) survey days that affected Resident #5.Findings include:A review of the facility's policy, Call Lights: Accessibility and Timely Response, dated 10/21/24, revealed, .Policy Explanation and Compliance Guidelines.3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system.A record review of the admission Record revealed the facility admitted Resident #5 on 2/13/23 with current diagnoses including Hemiplegia and Hemiparesis and Contractures of Right and Left Arms and… […]