Every finding on record at Trend Health and Rehab of Natchez, LLC

Based on interview, record review, and facility policy review, the facility failed to comply with state nursing facility staffing requirements by failing to ensure the nursing staff had a ratio of 2.8 hours of direct nursing care per resident per twenty-four (24) hours for five (5) of (14) days reviewed.Findings include:Review of the facility's Staffing Policy dated 7/1/2024, revealed, .The facility will have sufficient nursing staff.4. The facility PPD (Per Patient Day) for clinical will be 2.80 or greater, this is the minimum standard and may not in itself meet the sufficient nursing staff need.A record review of the Minimum Standards for Institutions for the Aged or Infirm for Rule 45.4.1 Nursing Facility, revealed, .To be classified as a facility, the institution shall comply with the following staffing requirements. 1. Minimum requirements for nursing staff shall be based on the ratio of two and eight-tenths (2.80) hours of direct nursing care per resident per twenty-four (24) hours. Staffing requirements are based upon resident census.Record review of the Staffing Grid dated 6/15/26 through 6/28/26, revealed that on 6/19/26 the staffing ratio was 2.73, on 6/21/26 it was 2.63, on 6/26/26 it was 2.24, on 6/27/26 it was 2.4, and on 6/28/26 it was 2.24 which were all below the 2.8 requirement.On 7/23/26 at 5:44 PM, an interview with the Director of Nursing (DON) revealed the facility scheduled direct care nursing staff to meet the state minimum staffing levels. She confirmed that she was notified of the staff shortage on the nightshift on 6/26/26 on the morning of 6/27/26 and was notified by nursing staff on the night of 6/27/26 of the shortage. On 7/23/26 at 6:10 PM, an interview with the Administrator revealed the facility used the state minimum requirement ratio for daily staffing.

Based on interview, record review, and facility policy review, the facility failed to ensure that 1 (one) of three (3) residents reviewed for dignity and respect was treated in a manner that maintained and upheld her personal dignity. This failure resulted in the resident feeling embarrassed and uncomfortable when two Certified Nurse Assistants (CNAs) made an inappropriate comment during personal care. Resident #1. Findings include: A record review of the facility policy Resident Rights updated 4/4/25 revealed, Employees shall treat all residents with kindness, respect, and dignity.Resident #1:Record review of the admission Record revealed the facility admitted Resident #1 on 5/20/25 with diagnoses including cerebral infarction.Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/25 revealed a Brief Interview for Mental Status (BIMS) summary score is 13, indicating Resident #1 is cognitively intact.A review of the facility's investigation revealed that on 9/17/25 at approximately 12:17 PM, Resident #1 reported to Social Services that two (2) staff members had made remarks that hurt her feelings and caused her to feel bad about herself. The Director of Nursing (DON) immediately informed the Administrator-in-Training (A-IT). Resident #1 reported that as she was leaving her room and heading toward the shower room, her gown was hanging off her shoulder, exposing part of her chest. Certified Nurse Assistant (CNA) #2 commented, Just leave her alone, she just wants the old men to look at her. Following her shower, CNA #1 assisted the resident with dressing and remarked that the resident was gaining weight and thought her brother was going to bring her some clothes that fit. Both comments made the resident feel embarrassed and bad about herself. The facility immediately initiated an investigation and reported the incident to the State Agency (SA) through the abuse hotline and to the Attorney General's Office (AGO). Both staff members were placed on administrative leave pending the investigation and were subsequently terminated for improper conduct.On 10/29/25 at 1:30 PM, during an interview with Resident #1, she confirmed that several weeks earlier, two (2) Certified Nurse Assistants (CNAs) spoke to her in a rude and disrespectful manner. While preparing for her shower, her gown did not fully cover her, and one of the CNAs commented, You just want the men to look at you. Resident #1 explained, That hurt my feelings because I don't want any men to look at me in that way. I'm a young woman and a nurse who had a stroke. She reported the comment made her feel embarrassed and uncomfortable. Resident #1 informed facility staff of the incident and requested that the two CNAs no longer assist with her care.On 10/30/25 at 3:00 PM, during an interview with the Administrator, she confirmed that on 9/17/25, the facility was notified of an incident involving Resident #1 and two Certified Nurse Assistants (CNAs) who made an inappropriate comment to the resident during care. The Administrator stated the comment was unprofessional and did not reflect the facility's expectations for maintaining resident dignity and respect. She confirmed that both CNAs were immediately removed from resident care pending investigation. The Administrator revealed Resident Rights Policy requires all staff to treat residents with respect at all times and prohibits language or behavior that could be perceived as demeaning. She confirmed both CNAs were interviewed and admitted that a comment was made as a joke. The Administrator stated the facility determined the behavior violated policy and both CNAs were terminated. She verified that on 9/17/25, all nursing staff received re-education on professional communication, resident dignity, and maintaining respectful interactions.On 10/30/25 at 3:15 PM, during an interview with the Director of Nursing (DON), she explained that on 9/17/25 she was notified by Social Services that Resident #1 had reported an inappropriate comment made by two Certified Nurse Assistants (CNAs) during care. The DON reported that the comment was unprofessional and inconsistent with the facility's expectations for treating residents with dignity and respect. She immediately ensured the resident was safe and that both CNAs were removed from resident care while the matter was reviewed. The DON confirmed she interviewed the CNAs involved, the resident, and relevant staff. Both CNAs admitted a comment was made as a joke. The DON indicated she counseled the resident, who expressed embarrassment and discomfort, and provided reassurance that her concerns were taken seriously. Following the investigation, both CNAs were terminated for unprofessional conduct that failed to uphold resident dignity. The DON verified that on 9/17/25, following the incident, all nursing staff received re-education on professional communication, sensitivity, and maintaining resident dignity at all times.On 10/30/25 at 3:30 PM, during an interview with the Social Services Director, she confirmed that on 9/17/25 Resident #1 reported two Certified Nurse Assistants (CNAs) had spoken to her in a rude and inappropriate manner during shower preparation, making a comment that left her feeling embarrassed and hurt. The Social Services Director explained she immediately notified the Director of Nursing (DON), documented the concern, and provided emotional support to the resident. She verified that the facility initiated a review the same day in accordance with the Resident Rights and Dignity Policy, which requires all staff to communicate respectfully and maintain each resident's dignity at all times.On 10/29/25 at 3:40 PM, during a phone interview with CNA #1, she explained that while assisting Resident #1 to get dressed following her shower, the resident mentioned her brother was supposed to bring her larger clothes because she had been gaining weight. CNA #1 agreed with the resident that her clothing appeared to be getting tighter. She denied making any comments intended to be rude or disrespectful and reported she was only agreeing with what the resident had said. CNA #1 added that after assisting the resident, the resident did not appear upset or indicate that her feelings had been hurt. She commented, I would never say anything to hurt a resident's feelings.On 10/29/25 at 3:45 PM, during a phone interview with CNA #2, she explained that on 9/17/25 she observed Resident #1 rolling down the hallway with her gown exposing her shoulder area. Another CNA asked her to assist the resident and help cover her up. CNA #2 recalled telling the other CNA that if the resident chose to move about the facility with her shoulder exposed, that's her business-this is her home. CNA #2 denied making any direct comments to the resident and reported she did not say anything out loud that the resident could have overheard or perceived as disrespectful. She emphasized that she always tries to respect residents' privacy and dignity.

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 failed to ensure a resident's right to smoke within the facility's designated smoke times during an annual recertification survey on 9/21/2023 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 11 deficiencies cited. (F550) Findings included: A review of the facility policy, Quality Assurance and Performance Improvement (QAPI) Plan of Action 2025, revealed, Purpose Statement .Quality Assurance and Performance Improvement .guides our organization's efforts to proactively provide the highest quality of care and services for residents, families, and staff .Feedback, Data Systems, and Monitoring .Quality Assurance Program Tools .This facility's QAPI systems and processes are maintained with an ongoing program that is dynamically designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care, and to resolve identified problems Record review of the Provider History Profile, revealed the facility received a citation for F550 - Resident Rights/Exercise of Rights on the previous annual recertification survey dated 9/21/2023. 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 9/21/2023, revealed the facility received a citation for F550, .Based on observations, interviews, record review, and the facility policy review, the facility failed to honor a resident's right to smoke at the designated times to smoke per facility's policy . During the current recertification survey, the facility failed to honor a resident's preference related to smoking during the scheduled smoking times, in accordance with the facility's designated smoking schedule, for one (1) of eighteen (18) residents reviewed for resident rights. On 4/23/25 at 3:37 PM, during an interview with the Director of Nursing (DON), she confirmed the facility was cited for the same deficient practice during their last recertification. She also confirmed 12:30 PM as one of the scheduled smoking times designated by the facility. She explained the deficiency was repeated due to the need to adjust the smoking time, as staff are usually busy during the 12:30 PM smoke break. She acknowledged that despite this, residents still have the right to expect to go out at the scheduled time. On 4/24/25 at 11:37 AM, during an interview with the Interim Administrator, she explained that since the 12:30 PM smoke break falls during the lunch period, the facility either needs to adjust the scheduled time or specifically assign staff to that task. The Interim Administrator agreed that residents have the right to expect to go out at the designated smoking time.

Based on observation, interviews, record review and facility policy review, the facility failed to investigate or determine root causes for Resident #38 for three (3) of seven (7) falls. (1/12/25, 2/13/25, and 2/25/25) Findings included: A review of the facility's Responsibility for Accident/Incident Reports Policy, dated 07/2016, revealed, It is the policy of this facility for all Incident and Accidents involving resident's to be investigated immediately upon knowledge of the incident. Procedure. Staff are to be trained how to investigate and document assessment of possible causes for the accident/incident. They are to obtain written statements from staff on duty and an possible witnesses to the incident. They are to document on the proper forms . A record review of the Admission Record revealed the facility initially admitted Resident #38 on 01/09/25 with diagnoses including Cardiac Arrest. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/25, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 12, which indicates moderate cognitive impairment. A record review of the Progress Notes, for Resident #38, dated 1/12/2025 at 9:26 AM, revealed, .This nurse was called to resident room by unit CNA (Certified Nurse Aide) R/T (related to) witnessed fall without injury. CNA stated 'resident slid to the floor and sat down when trying to get on the stand lift . The author was LPN #4. A record review of the Progress Notes, for Resident #38, dated 2/13/25 at 11:18 AM, revealed, .This nurse was called to Therapy, when entering the room noted resident laying on the floor on her left side .immediately started c/o (complaining of) being dizzy .Resident left the facility at approx (approximately) 10:10 AM .Nurse called report to (Proper Name of Acute Care Hospital_ . A record review of the Progress Notes, for Resident #38, dated 2/25/25 at 15:30 (3:30 PM), revealed, This nurse was called to residents room by CNA upon entering the room resident was sitting on bed. Noted knot to left side of forehead noted bleeding . Another note dated 2/25/25 at 14:14 (2:14 PM) revealed, This nurse assisted floor nurse .with sending resident to ER (emergency room ) DT (due to) unwitnessed fall with head injury . A record review of the medical record for Resident #38 revealed there was no facility fall investigation (Fall Evaluation Tool) completed related to the falls that occurred on 1/12/25, 2/13/25, and 2/25/25. There was a Fall Evaluation Tool, for falls that occurred on 1/17/2025, 1/25/25, 1/28/25, and 2/27/25. On 04/21/25 at 10:11 AM, during an observation and interview with Resident #38, she was sitting in her wheelchair at the bedside. Resident #38 stated that she had fallen three (3) different times. On 04/23/25 at 10:55 AM, during an interview with the facility's Director of Nursing (DON), she explained that an investigation should be completed each time a resident falls, even when a resident experiences more than one fall in the same day. The DON stated that each incident should be reviewed separately to determine the cause and to implement interventions to prevent recurrence. On 04/24/25 at 10:17 AM, during a follow up interview with the DON, she stated she was not aware that Resident #38 had experienced a fall on 01/12/25. She acknowledged there should have been an incident report completed for that fall, explaining that incident reports help identify the circumstances of a fall and guide the implementation of preventive interventions. The DON stated she was also unaware of the fall that occurred on 02/13/25. She confirmed she had knowledge of the fall on 02/25/25 but admitted she failed to complete the incident report, stating she became sidetracked and forgot. She confirmed that all falls should be documented and investigated.

Based on observation, interview, record review, and facility policy review, the facility failed to honor a resident's preference related to smoking during the scheduled smoking times, in accordance with the facility's designated smoking schedule, for one (1) of eighteen (18) residents reviewed for resident rights, Resident #15. Findings included: A review of the facility policy titled, A Matter of RIGHTS, undated, revealed, A Guide to Your Rights and Responsibilities as a Resident .Dignity and Respect .You have the right to dignity and respect in the care you receive and the setting you live in. This right includes the right: to be treated as an individual .It also means you have a right to expect care and a residential setting .reflects your individual preferences . A record review of the Admission Record revealed the facility admitted Resident #15 on 7/5/24 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/25 revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated he was cognitively intact. A record review of the facility's Resident Smoking Schedule revealed 12:30 PM as one of the designated times for resident smoking breaks. On 4/23/25 at 12:30 PM, an observation revealed Resident #15 was waiting to go outside for a smoke break. No staff was present to assist him. During an interview at this time, Resident #15 stated that staff were often late taking him out to smoke or sometimes he did not get to go at all during the scheduled time. He expressed that this was upsetting because he enjoyed both smoking and the opportunity to go outside for fresh air. He stated that the outdoor time helped him feel more relaxed and provided a sense of freedom. He added that since this is his home, he felt he and other residents should be treated with more consideration, stating staff should be more consistent in honoring the outdoor smoking schedule. On 4/23/25 at 12:45 PM, an observation revealed no staff had yet come to take Resident #15 or the other residents outside to smoke. On 4/23/25 at 12:45 PM, during an interview with the Staff Development Licensed Practical Nurse #1 (LPN), she confirmed the B Hall staff was scheduled to take the residents out to smoke. When asked if a staff member was currently assigned, she responded that she would find the assigned Certified Nurse Aide (CNA). On 4/23/25 at 12:50 PM, in an interview with CNA #1, she explained she was originally assigned to take the residents out to smoke today, but stated it was not a good time because she needed to change two (2) residents. She further stated that smoking times were frequently delayed because staff were often busy during that time. On 4/23/25 at 3:37 PM, the Director of Nursing (DON) confirmed 12:30 PM was a scheduled smoke time for residents. She explained that the facility needed to adjust the smoking time because staff were usually busy during the 12:30 PM smoke break. The DON confirmed the residents had the right to be taken out for a smoke break by the facility staff at the scheduled times designated by the facility.

Based on interview and record review, the facility failed to ensure residents receive mail on Saturdays, which affected one (1) of one (1) resident council members reviewed and had the potential to affect all 61 residents residing in the facility. Resident #26. Findings included: A review of the facility's policy titled, A Matter of RIGHTS, undated, revealed, A Guide to Your Rights and Responsibilities as a Resident . Dignity and Respect, you have the right to dignity and respect in the care you receive and the setting you live in. This right includes the right: to be treated as an individual . It also means you have a right to expect care and a residential setting . that reflects your individual preferences . On 4/23/25 at 10:30 AM, during a resident council meeting, Resident #26, the council president, reported that residents did not consistently receive mail on Saturdays. She stated that this concern had been brought up at every council meeting and confirmed that although some nurses would deliver the mail in the past, it was not received every Saturday. All residents in attendance confirmed they did not receive mail consistently on Saturdays and would like to receive it regularly. On 4/23/25 at 11:20 AM, during an interview with the Director of Nursing (DON), she explained that residents not receiving mail on Saturdays had been a concern. She stated that it was the Registered Nurse (RN) Supervisor's responsibility to ensure mail was distributed and reported that she had addressed the issue and had disciplined staff for failure to distribute mail. The DON stated it was important that residents receive their mail on Saturdays. On 4/23/25 at 2:47 PM, during an interview with the Activities Director, she stated that the mail issue had been ongoing and that she mentioned it during the morning meeting. She confirmed the residents should receive their mail on Saturdays and was unsure why the issue persisted. On 4/24/25 at 9:09 AM, in a follow-up interview with Resident #26, she stated that recently, residents had not been receiving their mail on Saturdays at all. A record review of the Admission Record revealed the facility admitted Resident #26 on 2/2/18 and she had current diagnoses including Iron Deficiency Anemia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/25 revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated she was cognitively intact A record review of the Resident Council meeting minutes, dated 2/14/25, revealed residents had concerns of not consistently receiving mail on Saturdays.

Resident #45 PASARR Final Version Based on interview and record review the facility failed to update the Level II Preadmission Screening and Resident Review (PASSAR) to reflect recent mental health diagnoses for one (1) of 18 residents sampled. Resident #45 Findings include: A review of the facility policy, Pre-admission Screening Application for Long Term Care (PASRR), 2/2024 revealed . A PASRR is required for every resident admission to long term care .There should be a Change In Status Form completed if resident is sent to a psychiatric hospital or other significant change . A record review of the facility's Admission Record revealed the facility admitted Resident #45 on 10/13/22 with diagnoses including Unspecified Psychosis not due to a substance or known physiological condition (onset date 11/16/23) and Paranoid Schizophrenia (onset date 11/16/23). A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/25 revealed the staff's assessment of the residents' cognitive status was severely impaired. A record review revealed Resident #45 had no Level II PASSAR to address the most recent mental health diagnoses. On 04/22/25 at 08:40 AM, an interview with the Director of Nursing (DON) revealed she acknowledged the failure of the facility to ensure the resident's Level II PASARR was updated to reflect the resident's two most recent mental health diagnoses. The DON stated it is the responsibility of the Social Services Director to make sure the Level II PASARR contains current information. The DON confirmed the importance of having the PASARR updated with the resident's current medical information is to assure the resident is appropriately placed. The DON noted she expected the Level II PASARRs to be done immediately as changes occur to a resident's condition. On 04/22/25 at 8:48 AM, an interview with the Social Services Director (SSD) revealed she affirmed that the resident's Level II PASARR did not reflect the resident's most recent mental health diagnoses. The SSD confirmed it is her responsibility to keep this record updated. The SSD noted that going forward she will make sure to have all Level II PASARRs up to date. On 04/22/25 at 9:27 AM, an interview with the Administrator confirmed the facility's failure to maintain an updated Level II PASARR to reflect the residents' most recent mental health diagnoses. The Administrator reported that the Social Services Director was responsible for maintaining updated Level II PASARRs. The Administrator acknowledged that the importance of having an updated Level II PASARR is to ensure appropriate placement for the residents. The Administrator stated the facility will provide training and in-service for the SSD to make sure she understands how to stay up to date with this record.

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow infection prevention practices by not ensuring respiratory equipment was properly stored when not in use for one (1) of two (2) residents reviewed for respiratory services. (Resident #37) Findings Included: A review of the facility's Nebulizer and Oxygen Tubing Storage Policy, dated April 2007, revealed, .It is the policy of this facility to decrease the risk of potential and/or direct exposure to infectious disease, air contaminants and bacterial exposure. We will provide our residents with the proper storage and cleaning of respiratory equipment. Procedure .These tubings will be .stored in a dated plastic bag when not in use . On 4/22/25 at 7:37 AM, during an observation, Resident #37's oxygen and nebulizer tubing were observed unbagged, lying on each piece of equipment. No clean storage method was in place. A record review of the Admission Record revealed the facility admitted Resident #37 on 11/15/24 with diagnoses including Chronic Obstructive Pulmonary Disease. A record review of Resident #37's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired. On 4/22/25 at 8:00 AM, during an interview with the Director of Nursing (DON) at Resident #37's bedside, she confirmed the oxygen cannula and nebulizer tubing/masks were not bagged and stated they should be kept in a bag when not in use to prevent the spread of respiratory infection. She explained that it is the Sunday night cart nurse's responsibility to bag and change out tubing for each resident. On 4/23/25 at 2:47 PM, during an interview with Licensed Practical Nurse (LPN) #1, the Infection Preventionist (IP) Nurse, she stated that nasal cannula, oxygen, nebulizer tubing, and masks should be kept in a bag to prevent respiratory infections. She further stated they should be changed weekly by the Sunday night nursing staff and confirmed that this task appears on the Medication Administration Record (MAR).

Based on observation, interviews, record review, and facility policy review, the facility failed to follow the physician's order to provide a nutritional supplement with meals to support nutritional status for one (1) of eighteen (18) sampled residents, Resident #27. Findings included: A review of the facility's policy titled Initiation of Order Changes and Discontinuation of Medications, dated 2/2012, revealed, .Procedure .The nurse will assure that the order is complete with date, time, drug, dose, route, and how often to be administered . A record review of the Admission Record revealed the facility admitted Resident #27 on 12/22/21 and she had current diagnoses including Unspecified Dementia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/22/25 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated her cognition was severely impaired. A record review of the Order Summary Report revealed Resident #27 had a Physician's Order, dated 8/29/24 for Regular diet .Add [NAME] (Boost, a type of nutritional drink) supplement to all meals . A record review of the meal tray card, dated 4/22/25, for Resident #27 revealed there was no supplement listed under the Diet portion of the card to reflect the Physician's Order. On 4/21/25 at 11:46 AM, during a dining observation, Resident #27 was observed without a meal supplement beverage on her tray. On 4/22/25 at 12:00 PM, during a second dining observation, Resident #27 again was not served a meal supplement beverage on her tray. On 4/22/25 at 12:10 PM, during an interview with Resident #27, she stated that she only liked sweets and mashed potatoes with no gravy. She confirmed that she would drink a nutritional supplement shake if she had one. On 4/22/25 at 12:45 PM, during an interview with the Dietary Supervisor (DS), she stated that Resident #27 was not served a nutritional supplement with her meals because there was no order written to provide supplements with meals. She added that the only additional nutrition the resident received was snacks delivered to the floor. On 4/23/25 at 7:33 AM, during an interview with the Director of Nursing (DON), she confirmed the resident had a physician's order dated 9/3/24 for a nutritional supplement shake with all meals. She explained that orders are reviewed during morning meetings and should have been communicated to the dietary department. She acknowledged the failure in communication and emphasized that physician orders are intended to direct resident care. On 4/23/25 at 7:44 AM, during an interview with the Administrator, she acknowledged that the facility failed to follow the physician's order dated 9/3/24 to provide a nutritional supplement with all meals for Resident #27. She emphasized the importance of staff following physician orders and stated the facility would ensure reviews are used to cross-check physician orders.

Based on observation, interview, and facility policy review, the facility failed to store food in accordance with professional standards for food safety by not discarding expired items, failing to refrigerate opened perishable items, and improperly storing dry goods, for one (1) of two (2) kitchen observations. Findings included: A review of the facility's policy, Food Safety Requirements, dated ,d+[DATE] revealed, Policy .Food will be stored . in accordance with professional standards for food service safety . Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process .b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms . 3. Facility shall inspect all food .for safe transport and quality upon delivery/receipt and ensure timely and proper storage .c. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer .Practices to maintain safe refrigerated storage include .iv. Labeling, dating, and monitoring refrigerated food . so it is used by its use-by date . or discarded . On [DATE] at 10:27 AM, during an observation of the kitchen and interview with the Dietary Supervisor (DS), Refrigerator #1 contained one (1) opened bag of coleslaw mix with a manufacturer's use-by date of [DATE]. The contents of the bag were grayish in appearance. An observation of the pantry revealed a scoop sitting inside the bin of sugar, two (2) opened 48-ounce bottles of lemon juice sitting on the shelf with instructions to refrigerate after opening, and three (3) soft potatoes with shriveled skin. The DS acknowledged the expired coleslaw, the improperly stored juice, the scoop left in the sugar, and the overly ripe potatoes. She stated she was new to the job but took responsibility for the deficiencies and intended to discard the expired items and bring the kitchen up to standard. She stated in-services are held weekly. On [DATE] at 10:45 AM, during an interview with the Cook, she stated that the previous supervisor checked expiration dates but that is no longer happening due to the new DS. She explained that if she notices expired or undated items in the refrigerator, she throws them away. She reported that staff are in-serviced monthly on food safety. On [DATE] at 8:37 AM, during an interview with the Corporate Nurse (CN), she acknowledged the outdated coleslaw mix, improperly stored lemon juice, scoop left in the sugar, and overly ripe produce. The CN stated the DS is responsible for ensuring food quality and hygiene and affirmed the expectation that the DS ensures food is dated, stored correctly, and discarded before expiration.

Based on observation, interview, and record review, the facility failed to ensure medications were stored securely for two (2) of five (5) residents reviewed for medication storage and administration, Resident #37 and Resident #50. Findings included: A review of the facility's policy titled, Medication Storage in the Facility, revised January 2018, revealed, .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Procedures .B .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . Resident #37 During an observation and interview on 4/22/25 at 7:25 AM, Licensed Practical Nurse (LPN) #3 retrieved an inhaler from Resident #37's bedside drawer, where it had been stored. LPN #3 stated the resident always kept it in the drawer in case she needed it and stated the medication should probably be kept locked up in the medication cart when not in use. A record review of the Admission Record revealed the facility admitted Resident #37 on 11/15/24 with diagnoses including Chronic Obstructive Pulmonary Disease. A record review of Resident #37's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired. A record review of the Order Review History Report revealed Resident #37 had a Physician's Order dated 11/15/24 for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT, 2 puffs inhale orally every four (4) hours as needed. Resident #50 During an observation and interview on 4/22/25 at 7:41 AM, Resident #50 was given a Budesonide nebulizer vial that was left at the bedside by LPN #3. LPN #3 stated she leaves it with him each morning. A record review of the Admission Record revealed the facility admitted Resident #50 on 5/12/23 with diagnoses including Chronic Obstructive Pulmonary Disease. A record review of Resident #50's MDS with an ARD of 3/6/25 revealed a BIMS score of 12, which indicated the resident's cognition was moderately impaired. A record review of the Order Review History Report revealed Resident #50 had a Physician's Order dated 3/5/25 for Budesonide Inhalation Suspension 0.5 milligrams (mg)/2 milliliters (ml), one (1) vial orally two (2) times a day. On 4/22/25 at 7:55 AM, during an interview with the Director of Nursing (DON), she stated that medications should not be left in resident rooms because there are wandering, confused residents in the building who could ingest the medications. She further stated another risk would be residents giving themselves the wrong dose. She confirmed her expectation is that nurses administer medications appropriately and ensure secure storage.

Based on observation, interview, record review, and facility policy review, the facility failed to assess residents' ability to safely self-administer medications for two (2) of five (5) residents reviewed for medication administration, Resident #37 and Resident #50. Findings included: A review of the facility's policy titled, Self Administration of Medications, revised 11/2000, revealed, When a resident requests to self administer his/her medication, the resident will be assessed by the interdisciplinary team to determine if this practice is safe. This decision will be made by the interdisciplinary team before the resident exercises this right .Determining factors regarding residents' capabilities for self administration of medication discussed by the interdisplinary (sic) team are: 1) Mental ability: A resident must be fully oriented to time, place and person. Cognitive skills for decision must be consistent and reasonable .3) Must be physically able to accept control of the medication .5) Must have a physician's order . Resident #37 On 4/22/25 at 7:25 AM, during an observation and interview, Licensed Practical Nurse (LPN) #3 was observed giving Resident #37 an albuterol sulfate inhaler. LPN #3 retrieved the inhaler from the resident's bedside drawer, where it had been stored. Resident #37 then self-administered the inhaler. LPN #3 stated the resident always self-administers the inhaler and keeps it in the drawer in case she needs it. LPN #3 stated the medication should probably be kept locked up in the medication cart when not in use. A record review of the Admission Record, revealed the facility admitted Resident #37 on 11/15/24 with current diagnoses including Chronic Obstructive Pulmonary Disease. A record review of Resident #37's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident's cognition was moderately impaired. A record review of the Order Review History Report revealed Resident #37 had a Physician's Order, dated 11/15/24, for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Micrograms/Asthma Control Test) 2 puff inhale orally every 4 hours as needed . Resident #50 On 4/22/25 at 7:41 AM, during an observation and interview, Resident #50 was given a budesonide nebulizer vial by LPN #3 that was left at the bedside. Resident #50 did not take the medication at that time. LPN #3 stated the resident self-administers medications and she leaves it with him each morning because he can give his own medications. A record review of the Admission Record, revealed the facility admitted Resident #50 on 5/12/23 with current diagnoses including Chronic Obstructive Pulmonary Disease. A record review of Resident #50's MDS dated [DATE] revealed a BIMS score of 12, which indicated the resident's cognition was moderately impaired. Further review revealed he had impairment on one side of the upper extremity. A record review of the Order Review History Report revealed Resident #50 had a Physician's Order, dated 3/525 for, Budesonide Inhalation Suspension 0.5 MG/2ML (Milligrams/Milliliters) 1 vial orally two times a day . A review of the medical records for Resident #37 and Resident #50 revealed no documentation that an interdisciplinary team assessment had been completed to determine their ability to safely self-administer medications, nor were there any physician's orders authorizing self-administration. On 4/22/25 at 7:55 AM, during an interview with the Director of Nursing (DON), she confirmed that neither Resident #37 nor Resident #50 had an assessment or physician order to self-administer medications. The DON explained that Resident #50 has contractures in his hands, making it difficult to operate the nebulizer vial, which could lead to missed doses and potential hospitalization s due to his lung disease. The DON stated it is her expectation that nurses follow physician orders and assess appropriateness of self-administration.

Based on observation, interview, record review, and policy review, the facility failed to ensure oxygen-in-use signage was posted on the door for one (1) of one (1) resident reviewed for oxygen safety, Resident #39. Findings included: A review of the facility's policy, Oxygen Safety (undated), revealed: .General Guidelines .5. 'No Smoking' signs must be clearly visible in areas where oxygen is stored or in use. On 4/21/25 at 11:00 AM, Resident #39 was observed lying in bed with oxygen flowing at three (3) liters per minute. There was no oxygen caution signage posted on the resident's door. On 4/21/25 at 1:42 PM, during an observation and interview with Licensed Practical Nurse (LPN) #2, she confirmed there was no oxygen caution signage on Resident #39's door. She stated there should be one since oxygen was in use. On 4/22/25 at 11:15 AM, during an interview with the Director of Nursing (DON), she stated, there had been signage on the doors and explained there is a resident who is a known wanderer and likely removed the signs. She stated they had run out of signage for a couple of days while searching for replacements. She confirmed signage should be posted on the door and acknowledged that its absence represented a safety hazard. A record review of the Admission Record revealed the facility admitted Resident #39 on 11/3/21 with diagnoses including Chronic Obstructive Pulmonary Disease. A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/25 revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. A record review of the Order Review History Report revealed a physician's order dated 8/27/24 for Oxygen at 3 L (liters) per nasal cannula continuously .

Based on observation, interviews, record review and facility policy review, the facility failed to supervise and protect a dependent resident to prevent injury for one (1) of five (5) residents reviewed for accidents. Resident #52 Finding include: Review of the facility policy, titled Accident Prevention revealed, Each resident shall receive adequate supervision and assistive devices to prevent accidents. The environment will be free from accidental hazards for all residents, staff, and visitors through: . Record review of the facility's policy, Resident Rights with latest revision date 11/17 revealed, All residents in a long term care facility have rights guaranteed to them under Federal and State Law. Residents residing at this facility will be guaranteed a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. These rights include: . 37. To a safe .environment. On 9/18/23 at 08:45 AM, an observation revealed Resident #52 sitting in bed with the head of the bed elevated and dry shaving himself. There was no shaving cream or soap on the resident's face. The resident had several cuts on his face with blood running down his face. The resident said he was told to shave himself because the Certified Nursing Assistant (CNA) did not have time. The resident said he told the CNA to give him the razor, and he would shave himself. Resident #52 revealed he's having problems shaving himself because he only has use of one hand, as he is paralyzed on his left side. The resident also said he cannot hold the mirror and shave himself. There were three cuts on his face and one on his neck. In an interview on 9/18/23 at 9:06 AM, with CNA #1, he stated the resident told him he wanted to shave himself, so he gave the resident the razor. CNA #1 confirmed he left the resident unsupervised while he provided care for another resident. CNA #1 commented that Resident #52 always bleeds when he is shaved. He stated that Resident #52 even bleeds when he shaves him, because the resident takes a blood thinner. CNA #1 said the resident did have an electric razor, but it was no longer available, as it broke. During an interview with the Director of Nursing (DON), on 9/18/23 at 10:00 AM, she confirmed CNA #1 failed to supervise the resident while the resident was shaving himself. The DON confirmed Resident #52 should not have been shaving himself unsupervised, as the resident had not been assessed to make sure that he's safe to shave himself without assistance. After acknowledging that the resident cut himself in four (4) different places, the DON confirmed the resident is not safe to shave himself without assistance. On 9/19/23 at 9:07 AM, during an interview with Licensed Practical (LPN) #1, she said the staff is trained to always supervise the residents while shaving. The resident is only able to shave themselves when they have been assessed and educated with demonstration that they can safely shave without supervision. Review of the Certified Nursing Assistant (CNA) #1's, CNA Performance and Skills Evaluation, dated 8/31/22, revealed he was in-serviced on accidents/incidents and shaving residents. During an interview on 9/19/23 at 10:30 AM, the Nurse Practitioner (NP) confirmed the resident is taking both Aspirin and Plavix because he has had a Cerebral Vascular Accident (stroke) and the medication prevents the blood from clotting. The NP confirmed the resident is dependent on staff to assist with Activities of Daily Living (ADL's) because he only has the use of one hand and cannot provide care without assistance. The NP said the resident should not shave himself without supervision. On 9/21/23 at 11:56 AM, during an interview the Administrator, revealed he did not know the resident's electric razor was not working. The Administrator said he would have provided another electric razor. The Administrator confirmed Resident #52 should not be left unsupervised with a razor to shave himself. Record review of the Face Sheet for Resident #52 revealed the resident was admitted by the facility on 3/02/22, with diagnoses that included Hemiplegia following Cerebral Infraction Affecting Left Non-Dominant Side, Coronary Artery Disease (CAD), Muscle Weakness and Cognitive communication. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/10/23 revealed Resident #52 had a Brief interview for Mental Status (BIMS) of 14, which indicated Resident #52 was cognitively intact. 43283

Based on interviews, record reviews and facility policy reviews, the facility failed to ensure that the comprehensive care plan was implemented by leaving a dependent resident unsupervised while performing Activities of Daily Living (ADL) for one (1) of 20 sampled residents. Resident #52 Findings include: Review of the facility's, Care Plan Policy, revised 8/17, revealed . The care plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practical physical mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged, and must be consistent with resident's written plan of care. The facility shall use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility staff shall follow the care plan . Record review of the facility's Care Plan for Resident #52 revealed the resident had a Problem/Need identified on 3/2/22, as Resident has a DX (diagnosis) of Hemiplegia/Hemiparesis, with the goal that the resident will have no complications related to the diagnosis through the next review date of 11/10/23. One of the approaches to meet this goal was to assist the resident with ADLs as needed. During an observation on 9/18/23 at 8:45 AM, Resident #52 was observed dry shaving himself in his room without supervision. The resident was observed with bright red blood running down his face. The resident said he was told by Certified Nursing Assistant (CNA) #1 to shave himself, because he was busy with another resident. During an interview on 9/18/23 at 9:06 AM, CNA #1 confirmed he failed to follow the care plan because the care plan states to assist with ADL's. The CNA revealed he was aware that Resident #52 could only use his right hand. The CNA added that the resident had an electric razor, but it didn't work anymore. The CNA explained he thought Resident #52 could shave himself without hurting himself and didn't think the resident would try to dry shave himself. During an interview on 9/18/23 at 10:00 AM, with the Director of Nursing (DON), she confirmed that CNA #1 failed to follow the care plan for Resident #52 by not assisting the resident with shaving, as with the use of only one hand, the resident needed help. During an interview on 9/19/23 at 9:30 AM, with Licensed Practical Nurse (LPN) #2, and Registered Nurse (RN) #1, they both confirmed CNA #1 failed to follow the care plan. Both nurses said the CNA should have stayed in the room with the resident to assist him because with only the use of one hand, the resident could not hold the mirror and shave at the same time. Both nurses said they expect the staff to follow the plan of care. During an interview on 09/21/23 at 11:56 AM, the Administrator revealed he did not know the resident's electric razor was not working. The Administrator said he would have provided another electric razor. The Administrator confirmed Resident #52 should not be left unsupervised with a razor to shave himself. Record review of the Face Sheet for Resident #52 revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Hemiplegia following Cerebral Infraction affecting the left non-dominant side, Coronary Artery Disease, Muscle Weakness and Cognitive Communication Deficit. Record review of the quarterly Minimum Data Set (MDS), with the Assessment Reference Date (ARD) of 08/10/23, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.

Based on record review, interview, Payroll Based Journal review and facility policy review, the facility failed to ensure sufficient nursing staff were available to provide nursing services for the resident's highest practicable well-being for the third quarter of 2023 for eight (8) of 26 weekend days and for three (3) days in the past two (2) weeks. This has the potential to affect all 72 residents in the facility. Findings include: A record review of the facility's policy Nursing Services-Staffing with latest revision date 11/17 revealed 1. Staffing- The facility will have sufficient nursing staff twenty-four hours every day to provide nursing and nursing related services to attain or help maintain the highest practicable physical, mental, and psychosocial well-being of each resident as is determined in the comprehensive assessment and the resident care plan. 2. The facility will comply with established staffing requirements by the individual state governing agencies . On 09/18/23 at 09:06 AM, during an interview with Certified Nurse Aide (CNA) #1, he explained Resident #52 asked him for a razor this morning and he gave the resident the razor, because he didn't have time to shave the resident. The CNA confirmed he left the resident unsupervised while he provided care for another resident, and Resident #52 ended up cutting himself with the razor. On 09/18/23 at 11:50 AM, during an interview and observation with Resident #66 in his room, he reported the turnover of CNAs at the facility is bad, and the CNAs are always working short and cannot wait on the residents properly to provide all the care that's needed. He explained CNAs are short and quick and don't always have time to do everything they need for him and other residents and this has happened on all shifts. He tries to do everything for himself, so he does not have to ask for help much. On 09/18/23 at 11:55 AM, during an interview with CNA #3, she explained she was called in this morning and arrived around 09:30 AM. She revealed she gets called in several times a week. The CNA reported that her resident assignment averages 10 or more residents, but it depends on the number of CNAs working the shift. The CNA reported she does not always have time to complete all her duties, it just depends on if the staff is short for the shift. On 09/18/23 at 02:15 PM, during an interview with CNA #1, he explained the staffing has been short on CNAs for a long time. On 09/18/23 at 03:21 PM, during an interview with Resident #51, he explained the CNAs have been working short for some time. It will get better and then bad again. He explained he is always staying wet from urinating, and it drenches his pants and runs into his right shoe. Some CNAs are good, but others are not, and this is on all shifts. The resident stated he tries to do for himself, so he doesn't have to ask for help. He explained the shortage is especially bad on the weekends. On 09/19/23 at 08:30 AM, during an interview with CNA #4, she explained that one of the Licensed Practical Nurses (LPNs) had a crisis at home and had to leave, so the Registered Nurse (RN) supervisor is on the medication cart now. She reported staff have been working short for a long time, but the new Director of Nurses (DON) has cracked down on the call-ins. The call-ins were bad, especially the weekends, and the staff would work short. She explained this has happened on all shifts. On 09/19/23 at 10:10 AM, during an interview with CNA #5, she explained the number of residents each shift depends on the number of CNAs working. The number of CNAs needed on day shift to make sure all duties are completed is eight (8) CNAs, but day shift usually works with six (6) aides. The facility usually works short one (1) or two (2) times a week. The CNA revealed that on some days she can complete all her duties and on other days, she cannot. The CNA stated that at one time, the facility used agency staff, but they are no longer using agency staff to help with the lack of staff. On 09/19/23 at 10:20 AM, during an interview with CNA #6, she explained she usually has 10 residents on her shift, depending on if CNAs call in. She revealed when they work short, they will have up to 14 to 15 residents with an average of 3-4 showers, depending on if any extra showers were carried over from the day before due to showers from the day before having to be postponed due to working short. The CNA explained she tries to complete all her assigned duties, but somedays it's impossible. She explained the CNA shortage averages maybe 1-2 times a week. The day shift works good with eight (8) CNAs on the day shift but will work with five (5) or six (6) on most days. On 09/20/23 at 11:50 AM, during an interview with RN #4, she explained she works as needed for the facility and sometimes she works several times a week and works 16 hours on the weekend as supervisor. Staffing on the weekend can be challenging due to call-ins. She has had to work the medication cart sometimes on the weekends leaving no RN supervisor for the evening shift. Some CNAs will come in early, and others will work over a couple hours to help the other shift. On 09/20/23 at 02:45 PM, during an interview with CNA #2, she explained CNA staffing has been short for a while. She averages 10-13 residents most days and some days does not get everything done. On 09/20/23 at 02:55 PM, during an interview with CNA #4, she explained the facility has no agency working in the building but does work short 1-2 times a week. Day shift usually works well with eight (8) CNAs but most of the time they have 5 or 6 and it is hard to get all the work done on those days. On 09/20/23 at 03:45 PM, during an interview with the Administrator, he explained the time clock goes directly to PBJ (Payroll-Based Journal Reporting) for the facility after he approves it. He explained sometimes a fingerprint on the time clock may not have carried over or sometimes the CNA students or nurses in training may not have carried over. He reported he thinks some days may have been entered in error and was not aware of low weekend staffing being triggered. On 09/21/23 at 09:10 AM, during an interview with Licensed Practical Nurse (LPN) #2, she explained she works 11-7 shift on the A, B, and left side of the C hall. She stated she usually works with three (3) to four (4) CNAs on the 11-7 shift, but at times, there have been only two (2) CNAs. She revealed she has many times had to help with providing care and has had to stay over on the day shift to finish up the charting that she didn't have time to do. On 09/21/23 at 10:50 AM, during an interview with the DON, she explained she does not know the full depth of staffing and what all is currently needed to fulfill the staffing requirement, but she does understand if the PBJ triggered short, it is what it is. She expects adequate staff to meet all residents' needs. On 09/21/23 at 11:00 AM, during an interview with LPN#1, she explained she has been at the facility for over one year and the facility has not used Agency for staffing during that time. Staffing has been a challenge but mostly due to the call ins. The facility currently needs CNAs for all shifts. Four (4) CNAs are needed for 7-3 and 3-11 shift and three (3) CNAs are needed for 11-7 shift. LPN #1 revealed the facility does do CNA classes that she teaches and will be offering one soon. On 09/21/23 at 09:30 AM, during an interview with RN #3, she explained she works 11-7 shift and some shifts there are plenty of CNAs and others not so much. RN #3 reported they would like to work with five (5) or six (6) CNAs but have been short with only 3 CNAs on night shift and has had to help with care at times resulting in staying over several hours to complete her charting duties. On 09/21/23 at 12:30 PM, during an interview with the Administrator, he explained on 04/01/23 the hours for CNAs were incorrect on the PBJ report that was submitted. He explained there may have been other days in error also. He explained that since the COVID-19 pandemic staffing has been an issue. Currently the facility is using student CNAs to get more CNAs in the facility, offering advertisements for nurses and offering all shift incentives for extra shift work. The company has agreed to increase the sign-on bonus, hourly pay, and double the incentive pay. He expects staffing to be sufficient to care for all the residents and their needs. Record review of Resident #51's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/23 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #51 was cognitively intact. Resident required limited assist for dressing self-performance of one person assist. Mobility devices: wheelchair (manual or electric) was checked. Record review of Resident #66's quarterly MDS with an ARD of 08/14/23 revealed a BIMS score of 14, which indicated Resident #66 was cognitively intact. Resident required extensive assistance for toilet use of one person and one person assistance for bathing. Record review of the facility's PBJ Staffing Data Report CASPER Report 1705D FY Quarter 3 2023 (April 1 - June 30) revealed . Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low . Record review of the facility's Staffing Grid for the Third Quarter 2023 and Period Total Reports revealed low staffing for eight (8) of 26 days on the weekend with low staffing. Record review of the facility's Staffing Grid for 9/5/23 through 9/18/23 and Period Total Reports revealed three (3) out of 14 days with low staffing. Record review of the facility's Facility Assessment completed on 10/31/22 revealed . Facility resources needed to provide competent support and care for our resident population during normal business operations and during emergencies: . Staffing plan: . As a facility we provide staff to adequately meet the acuity and needs of daily care for our resident population. Our daily census determines our budget for allotted staff and PPD is calculated daily to ensure compliance with staffing PPD . number of staff needed daily as an average: . Nurse aides 24 .

Based on observation, interviews, and facility policy review, the facility failed to discard 30 cartons of chocolate milk that expired on [DATE] for one (1) of four (4) days of observations of the kitchen. Findings include Review of the facility policy Food Storage Labeling with a received date of ,d+[DATE], revealed, POLICY: The facility will ensure the safety and quality of food by following good storage .procedures .Identify the food item's use by date or expiration date . b. Foods stored in storage units will be survey routinely to identify and discard foods that have passed its manufacturer use-by date or expiration date .Refrigerator Storage--Weekly . Observation on [DATE] at 8:31 AM, during an initial tour of the kitchen with the dietary manager, observed 30 cartons of chocolate milk in the refrigerator with an expiration date of [DATE]. The milk was sitting in a black milk crate on top of the white milk in the refrigerator. The Dietary Manager said the staff use the milk in this refrigerator for the residents. During an interview on [DATE] at 8:50 AM, the Dietary Manager (DM) confirmed 30 cartons of chocolate milk in the refrigerator had expired on [DATE]. The DM stated the milk must have come in Friday afternoon because she did not see them Friday morning. She further explained the cook that worked Friday afternoon was responsible for checking the dates when the milk was delivered. The DM revealed no resident had received the expired milk on the morning of [DATE], as she had been informed by the Dietary Aide that she had noted the expiration dates on the milk and although she did not remove the milk or inform the DM of the expired milk, no residents had received the milk that morning. However, the DM admitted that she didn't know if any of the resident's received the expired chocolate milk over the weekend. On [DATE] at 9:38 AM, during an interview with the Dietary Aide, she revealed she did not know the chocolate milk was expired. The Aide commented that should she have known, she would have notified the DM and removed it out of the refrigerator. On [DATE] at 12:26 PM, during an interview with the night cook, he revealed sometimes, the milk is delivered in the evening. The cook said the milkman takes the expired milk and leaves fresh milk. The cook added that he checks the expiration dates on the milk prior to giving it to the residents. The cook said he did not know the chocolate milk was expired, but somebody should have recognized that the milk was expired prior to today. On [DATE] at 12:46 PM, during an interview with the milkman, he confirmed he normally delivers milk to this facility. The milkman said he takes the expired milk out of the refrigerator and discards it and replaces it with fresh milk. The milkman said he doesn't know how the milk was missed. He admitted he might have missed it. However, he has not had a problem with expired milk being left in a facility in the nine (9) years he's work for the company. During an interview on [DATE] at 12:49 PM, with the Director of Nurses (DON), she revealed the residents have not had any stomach issues. The DON said she didn't know if any of the residents had received any of the chocolate milk over the weekend, but she confirmed drinking expired milk can cause stomach problems with the residents. During an interview on [DATE] at 12:51 PM, the Administrator confirmed the milk should have been pulled out of the refrigerator and discarded. The Administrator said the Dietary Manager is responsible for checking the expiration dates and making sure the residents don't receive expired milk.

Based on interviews, record review and facility policy review, the facility failed to show evidence of an accurate Level I Preadmission Screening (PAS) to determine if the resident had a mental illness prior to admission to the facility for one (1) of 20 sampled residents. Resident # 56. Findings include: Review of the facility's policy, Pre-Admission Screening PAS/PASRR (MS only), with a revision date of 10/18, revealed, Anyone applying for admission into a nursing facility must be approved prior to the admission by the Division of Medicaid (DOM) and/or the appropriate Level II authority. The PAS (Preadmission Screening) with Level I PASRR (Preadmission Screening and Resident Review) must be submitted to DOM and approved prior to admission to a nursing facility regardless of payment source. Level I PASRR (Pre-Admission Screening and Resident Review) 1. Anyone applying for admission into a Title XIX certified facility must have a Level I PASRR that is completed, signed and dated by a physician licensed in the State of Mississippi. 2. The Level I PASRR will be submitted electronically to DOM. 3. The Level I PASRR may be dated up to 30 days prior to the date of admission. 4. The Level I PASRR screening is included in the PAS . A record review of the Preadmission screening (PAS) Summary and Physician Certification, dated 3/25/22, for Resident #56, revealed the facility documented that Resident #56 did not have a major mental illness, did not have a history of mental illness and did not take psychotropic medication or have a history of taking psychotropic medication. A record review of the Face Sheet for Resident #56, revealed an admitted [DATE] with diagnoses that included Schizophrenia, unspecified, Depression, unspecified, and Cocaine Dependence, uncomplicated. A record review of the Physician Orders, for the month of September 2023, revealed a physician order, with an order date of 3/24/22, for Quetiapine Fumarate (Seroquel) 100 mg (milligram) tab take 1 (one) tab PO (by mouth) QHS (every hours of sleep) for Schizophrenia. A record review of the Care Plan for Resident #52, revealed a problem with an onset date of 3/25/22 for Resident has potential for injury R/T (related to) Antipsychotic medications, Potential for altered mood state related to DX (diagnosis) of Schizophrenia problem onset date 3/25/22 and an additional problem identified on 3/25/22 as Potential for altered mood state related to Dx (diagnosis) of Depression. A record review of the Care Plan for Resident #52, revealed a problem with an onset date of 3/25/22 for Resident has potential for injury R/T (related to) Antipsychotic medications and an additional problem identified on 3/25/22 as Potential for altered mood state related to Dx (diagnosis) of Depression. A record review of the EMAR (electronic medication administration record) revealed Resident #52 is receiving Quetiapine Fumarate (Seroquel)100 mg every night for schizophrenia, with an order date of 3/24/22 and a start date of 3/31/22. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/4/23, revealed a Brief Interview for Mental Status (BIMS) score of seven (8) which indicated the resident had severe cognitive impairment. Additionally the MDS revealed an active diagnosis of Schizophrenia and listed Psychosis as a behavior. On 9/20/23 at 12:12 PM, in an interview with Director of Nursing (DON), she confirmed, the Pre-Admission Screening (PAS) was not documented correctly. She stated the Social Worker (SW) is responsible for completing the PAS. She revealed it should have been done before admission, to make sure that the facility can meet the needs of the resident. On 9/20/22 at 2:10 PM, in an interview with the SW, she revealed she is responsible for making sure the PAS is completed. She stated she has not been trained properly but it is her responsibility to make sure it is accurate. The SW said she mentioned to the Administrator that she did not feel comfortable looking at diagnosis or medications, because she's not a nurse and doesn't know what the medications are used for. The SW stated she did not know the resident had a diagnosis of Schizophrenia and was taking Quetiapine (Seroquel) upon admission. On 9/20/22 at 3:01 PM, in an interview with the Administrator, he confirmed it is the responsibility of the SW to complete the PAS. He stated that it is a team effort, but nobody does a final check to make sure everything is completed. He stated the PAS is done to make sure that the facility can meet a resident's needs.

Based on observations, interviews, record reviews, and the facility policy review the facility failed to honor a resident's right to smoke at the designated times to smoke per facility's policy for one (1) of four (4) residents that smoke. Resident #46. Finding include: Record review of the facility's Smoking Policy, revised 10/22 revealed, The decision with regard to smoking is a personal matter and should be treated as such . Residents will be supervised by facility staff . Record review of the facility's policy, Resident Rights with latest revision date 11/17 revealed, All residents in a long term care facility have rights guaranteed to them under Federal and State Law. Residents residing at this facility will be guaranteed a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. These rights include: 1. The right to exercise his/her rights without interference, coercion, discrimination, or reprisal and shall be supported by the facility in the exercise of these rights . 30. To be treated with dignity and respect . Record review of facility's Staff Assignment for Residents Smoke Breaks, revealed the department assigned to the designated smoking times every the two (2) hours, beginning at 8:00 AM and ending at 8:00 PM. CNAs are assigned to the 8:00 AM, 4:00 PM, 6:00 PM, and 8:00 PM smoke breaks; Housekeeping is assigned to 10:00 AM, Activities is assigned to 12:00 PM, and Dietary is assigned to 4:00 PM to the smoke breaks. On weekends, Housekeeping/Restorative Aid are responsible to the 12:00 PM smoke break. On 9/19/23 at 10:20 AM, during an interview with the Resident #46, he explained he has smoked for [AGE] years about one (1) pack a day. On 9/19/23 at 12:10 PM, observed resident #46 sitting at the nurse's station requesting to go smoke. He reported its past time to smoke, and he is ready for a cigarette. No staff were observed responding to resident's request to be taken out to smoke. On 9/19/23 at 12:40 PM, observed resident in the hallway continuing to wait for assistance to go smoke. Resident #46 complained that although there are designated times to smoke, it is often late. On 9/20/23 at 12:10 PM, observed Resident #46 at the nurse's station telling staff he is ready for a cigarette. Once again, he explained the smoke break is late again. Observed staff around the nurse's station and no one attempting to take the resident to smoke. On 9/20/23 at 12:30 PM, an observation revealed the Staff Development /Infection Preventionist with cigarettes in her hand. She explained she was going to take the resident to smoke at this time but was unable find a lighter. On 9/20/23 at 12:40 PM, Resident #46 was observed in the hall, still waiting for someone to assist him with a smoke break. On 9/20/23 at 2:00 PM observed Resident #46 sitting by the nurse's station on the A hall, resident was requesting staff to take him to smoke. Once again, no staff were observed assisting the resident to smoke. On 9/20/23 at 03:15 PM, during an interview with the Director of Nursing (DON), she explained she expects staff to follow the designated smoking assignments and times for residents to smoke. She confirmed smoking is a resident's right and should be respected as well as all residents' rights. She explained she is aware of how important smoking is to Resident #46. On 9/20/23 at 3:30 PM, during an interview with the Administrator, he explained he was not aware the residents were not smoking at the scheduled times allowed for the residents nor was he aware some staff were not following assignments. He confirmed smoking is a resident's right and should be honored. He expects the staff to follow the smoking assignments and schedule and to try and keep to the scheduled time. He is aware Resident #46 is always ready to go smoke and his right should be honored and respected. On 9/20/23 at 4:30 PM, during an interview with the Housekeeper Supervisor, she explained housekeeping has two (2) staff members that smoke and one of them usually takes the residents out to smoke at 10:00 AM. Today she reported a dietary staff worker took residents out to smoke at 10:00 AM, because her staff were busy. She reported housekeeping is often late on taking residents to smoke because she expects her staff to complete a task they are involved in, prior to taking the residents to smoke. She explained CNAs and kitchen staff also take residents out to smoke. On 9/20/23 at 4:40 PM, during an interview with the Activity Director, she explained the facility does not always follow the smoking assignment schedule, as she may not even be in the building at the time activities are assigned on the smoking schedule. She confirmed she did not take the residents out to smoke at 12:00 on 09/19/23, because she had gone on an outing with other residents and was not in the building. The Activity Director admitted she did not arrange for anyone to take her place today, because when the CNAs go out to smoke, they often take the residents that smoke out with them. On 9/21/23 at 2:10 PM, during an observation an interview with Certified Nurse Aide (CNA) #7, the CNA explained to Resident #46 that she will take him to smoke after she completes taking care of her residents. At this time, an interview with CNA #7 revealed residents are allowed to smoke every 2 hours. The CNA explained that although the staff are good at taking the residents out to smoke, it's just not always on time. On 9/21/23 at 2:15 PM, during an interview with the Dietary Manager (DM), she confirmed that for the 2:00 PM smoke break, the dietary staff are responsible for taking the residents to smoke. She explained at 2:00 PM, there are two (2) residents that smoke, and both are in wheelchairs, so two (2) kitchen staff members usually assist those residents with their smoke break. On 9/21/23 at 2:30 PM, Resident #46 was still waiting to be assisted to smoke. The DM explained there was no lighter in the box with the cigarettes, therefore in an effort to find a lighter, the smoking time was delayed. A record review of the Face Sheet revealed the facility admitted Resident #46 on 07/26/23, with diagnoses that included Cerebral Infarction due to Occlusion or Stenosis of Small Artery and Encephalopathy. Record review of 5-Day Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/02/23, revealed that Resident #46 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS also revealed that the resident currently used tobacco. Record review of facility's list of Smokers revealed Resident #46's name.

Based on observations, interviews, and facility policy review, the facility failed to ensure staffing information was posted in a prominent place readily accessible to resident and visitors for four (4) of four (4) survey days. Findings include: Review of the facility's policy, Posting of Staff, with a revision date of 10/22, revealed, As required by Federal mandate, on a daily basis, the facility must post the following data: 1. Facility Name 2. Current Date 3. Resident Census 4. Facility-specific shifts for the 24 hour period 5. Categories of nursing staff employed or contracted by the facility, per shift 6. Actual time worked for the specified categories of nursing staff 7. Number of nursing staff working per shift . Facility will display nurse staffing data in a clear and readable format and must be posted at the beginning of each shift, in a prominent place readily accessible to residents and visitors . On 09/18/23 at 11:00 AM, an observation revealed there was no posting of staffing noted throughout the building. On 09/19/23 at 3:35 PM, and observation revealed no posting of staffing noted throughout the building. 09/20/23 at 4:40 PM, an observation revealed there continued to be no posting of staffing noted throughout the building. On 09/21/23 at 9:00 AM, once again observations revealed there was no posting of staffing noted throughout the building. On 09/21/23 at 10:50 AM, during an interview with the Director of Nurses (DON), she explained she knows the staffing is required to be posted daily in a visible place where all residents, staff, and visitors can see. She explained the Staff Development nurse is responsible for posting staffing during the week. She is not exactly sure where the staffing is posted in the building, as this is her second week at the facility. On 09/21/23 at 11:00 AM, during an interview with the Staff Development Nurse, she revealed she is aware that daily posting of staffing is required and explained that she posts daily staffing by the time clock, however, she has not posted it this week. The Staff Development Nurse stated that for the weekends, she attaches the staffing to the assignment sheet and the nurses, or the supervisor are responsible for posting the staffing. On 09/21/23 11:35 AM, during an interview with the Administrator, he explained he expects staffing to be posted daily for all staff, visitors, and residents to see.