Ocean Springs Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Ocean Springs Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Feb 13, 2025

  Based on interviews, record review, facility policy review, and facility investigation review, the facility failed to implement care plan interventions for a Resident #1, who was identified as an elopement and wandering risk for one (1) of four (4) residents reviewed. Resident #1 On 2/08/25, at approximately 3:00 PM, Resident #1 exited the facility while unsupervised wearing a wander alarm device that was found to be inoperable. The resident was out of the facility unsupervised and walked approximately 0.7 miles for approximately thirty (30) minutes before being located by facility staff and returned to the facility, crossing a four-lane highway. […]

• Immediate jeopardy, isolatedF689Feb 13, 2025

  Based on observation, interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision and assessment and monitoring of a wandering alarm device to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 On 2/08/25, at approximately 3:00 PM, Resident #1 exited the facility while unsupervised wearing a wander alarm device that was found to be inoperable. […]

• Immediate jeopardy, isolatedF655Jul 26, 2023

  Based on interview, record review, and facility policy review the facility failed to implement baseline care plan interventions related to Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive for one (1) of four (4) sampled residents. Resident #1 The facility failed to implement the baseline care plan interventions for CPR when Resident #1, who had a Full Code status, was found to be unresponsive and without a pulse or respirations. The nurse incorrectly pulled another resident's chart who had a Do Not Resuscitate (DNR) order and did not initiate CPR or activate emergency services for Resident #1. The facility's failure to implement the baseline care plan resulted in Resident #1 not receiving CPR and emergency services. […]

• Immediate jeopardy, isolatedF678Jul 26, 2023

  Based on interviews, record review, and facility policy review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) and provide emergency services to an unresponsive resident for one (1) of four (4) sampled residents. Resident #1. Resident #1, who had a Full Code status, was found to be unresponsive and without a pulse or respirations. The nurse incorrectly pulled another resident's chart who had a Do Not Resuscitate (DNR) order. Therefore, the nurse did not initiate CPR or activate emergency services for Resident #1. The facility's failure to review the correct code status resulted in Resident #1 not receiving CPR and emergency services. The resident subsequently expired in the facility. […]

• Immediate jeopardy, isolatedF689Jun 10, 2021

  The State Agency (SA) conducted the complaint investigation (CI MS # ) from 6/7/21 through 6/10/21 and substantiated CI MS # related to elopement, when the facility failed to provide adequate staff supervision to prevent Resident #3's elopement from the facility on 5/22/21. Resident #3 was last seen at 8:00 PM and found at 10:06 PM. Resident #3 was missing unsupervised and away from the facility for approximately ninety-two minutes. The facility was not aware of Resident #3's absence until they made rounds and the resident was not in the building. Certified Nurse Assistant (CNA) #1 and CNA #2 went to look for Resident #3 and found her in a parked car. Resident was trying to crank car. Resident #3 was found one street over behind the facility. […]