McComb Community Care Center

Inspectors wroteBased on policy review, record review and interviews the facility failed to provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to a resident requiring such care or initiate the emergency response system in accordance with related physician's orders and the resident's advance directives for one (1) of four (4) sampled residents. Resident #1 The facility's failure to review and implement the code status according to the advance directives resulted in Resident #1 not receiving CPR and emergency services. The resident subsequently expired at the facility. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] and existed at: 42 CFR(s): [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to implement care plan intervention related to activities of daily living (ADL) care and hydration for one (1) of four (4) sampled residents, Resident #1. Findings Included: Review of the facility's policy, Care Plans, dated 1/15, revealed, .Each resident will have a plan of care to identify problems, needs and strengths that will identify how the team will provide care Record review of the admission Record revealed the facility admitted Resident #1 on 2/22/24 with current diagnoses including [NAME] Obstructive Pulmonary Disease (COPD). Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she had moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to provide activities of daily living (ADL) care, specifically nail care, for a dependent resident for one (1) of four (4) sampled residents, Resident #1. Findings Included: Review of the facility's policy titled, A.M. Care, dated 10/09, revealed, .A.M. (Morning) Care will be given to residents daily .Procedure .10. Provide nail care as needed . Record review of the admission Record revealed the facility admitted Resident #1 on 2/22/24 with current diagnoses including [NAME] Obstructive Pulmonary Disease (COPD).a Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she had moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide hydration care and services to one (1) of four (4) sampled residents, Resident #1. Findings Included: Policy review of the facility policy titled 'Water Pitchers/Water Glasses' with review date 10/09 revealed the policy stated, Each resident will be provided with ice water/tap water at the bedside .Responsibility Nursing Assistants. Record review of the admission Record revealed the facility admitted Resident #1 on 2/22/24 with current diagnoses including [NAME] Obstructive Pulmonary Disease (COPD). Record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated she had moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide the resident or the Resident Representative (RR) with written notification of the bed-hold policy at the time of transfer for one (1) of one (1) sampled residents reviewed for hospitalization. Resident #18. Findings Include: Record review of a typed statement on facility letterhead, dated September 13, 2024, and signed by the Administrator revealed, (Proper name of facility) does not have a policy regarding bed holds. On 09/13/24 at 8:16 AM, during an interview with the RR for Resident #18, he stated that he did not receive a call from the Business Office Manager (BOM) or anyone from the facility regarding his father's bed hold for the hospital transfer that occurred on 09/10/24. [...]

Inspectors wroteBased on staff interviews, record reviews, and facility policy review, the facility failed to implement the care plan interventions as reflected in the resident's comprehensive Care Plan related to a fall for one (1) of twenty-three (23) sampled residents. Resident #37. Findings Include: A review of the facility's policy titled Comprehensive Person Centered Care Plans, (D.3) dated 3/18, 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 .Definitions .Comprehensive Person Centered Care Plan (CCP) - contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines .Procedure: .4. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide timely incontinence care and oral care for one (1) of four (4) residents reviewed for activities of daily living (ADL) care. Resident #73 Findings Include: A review of the facility's policy titled A.M. Care, dated 10/09, revealed: Policy: A.M. Care will be given to residents daily. Responsibility: All Nursing Assistants . On 09/09/24 at 11:48 AM, during an interview, the Resident Representative (RR) of Resident #73 stated that the Certified Nursing Assistants (CNAs) did not regularly brush her daughter's teeth or wash her hair. She explained that her daughter was unable to perform personal care independently and could not feed herself. The RR expressed her wish was that staff would more consistently perform these tasks. [...]

Inspectors wroteBased on observation, staff interviews, record reviews, and facility policy review, the facility failed to provide urinary catheter care in a manner that prevents possible complications for one (1) of one (1) residents reviewed for urinary catheter care. Resident #18. Findings Include: A review of the facility's policy titled Catheter Care, dated 5/22, revealed, Catheter care is performed to keep the catheter insertion site clean .3. Cleanse around the area where the catheter enters the urethral meatus with an incontinent wipe in a downward motion about 4 inches . Discard soiled incontinent wipes and plastic bag appropriately. On 09/09/24 at 02:38 PM, during an observation and interview, it was noted that Resident #18 had a urinary catheter. The resident was unable to recall how long he had a urinary catheter, however, he stated that it had been for some time. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide respiratory care in a manner to prevent the possibility of complications as evidenced by oxygen tubing that was not dated to indicate weekly oxygen tubing/nasal cannula changes and not cleaning the oxygen concentrator filter as required for one (1) of one (1) resident reviewed for respiratory care. Resident #26 Findings Include: A review of the facility's policy titled Oxygen Therapy, dated 8/14 revealed, Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress .Procedure: . 8. Change tubing weekly. 9. Date tube when changed (weekly). [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure proper hand hygiene and enhanced barrier precautions were followed prior to providing care for a resident with an indwelling catheter, for one (1) of one (1) resident observed for urinary catheter care. Resident #18. Findings Include: A review of the facility's policy titled Enhanced Barrier Precautions (EBP), dated 4/24, revealed . Definition: 1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) in Nursing Homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (e.g. [...]

Inspectors wroteBased on record review, Resident [NAME] of Rights review and staff interviews the facility failed to ensure residents had readily available and reasonable access to their personal funds on weekends. This had the potential to affect 55 of 112 residents who had funds managed by the facility. Findings Include: Record review of the facility's policy, Resident [NAME] Of Rights, with a revision date of 11/2017, revealed, .A. Facility residents shall have the right to . 22. Manage his or her financial affairs. The resident must authorize the facility in writing to manage any personal funds and the facility must ensure the resident has reasonable and ready access to those funds . On 12/05/22 at 11:16 AM, in an interview with Resident # 29, he stated that he has a trust fund at the facility, but he is not able to get money on the weekends. [...]

Inspectors wroteBased on observation, record review, and facility and staff interviews, the facility failed to ensure a resident received services included in the plan of care related to a condom catheter for one (1) of 23 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure PRN (as needed) psychotropic drugs were discontinued or documented as necessary after 14 days for one (1) of five (5) residents reviewed for unnecessary medications. Resident # 57.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to store, prepare and serve food under a safe and sanitary manner; as evidenced by failure to document freezer and refrigerator temperature checks for two (2) of three (3) days of the survey, pork chops cooked and served to the residents after being thawed in the sink without room temperature running water, and failure to maintain a 200 parts per million (ppm) sanitizer level for the 3-compartment sink for two (2) of three (3) staff observed to check the sanitizer lever. These identified concerns placed all residents who received food/nourishment from the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) to include Activities of Daily Living, Pre-admission Screening Assessment Resident Review (PASARR), anticoagulant, and tube feedings for four (4) of 30 MDS assessments reviewed. Resident #84, #87, #96, and #129.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide Resident #87's tube feeding site care in a manner to prevent the possibility of cross contamination/spread of infection. Licensed Practical Nurse (LPN) #1 failed to wipe and/or clean the feeding tube site in the appropriate direction and rotate the Normal Saline soaked gauze with each wipe, or change to a new gauze. This concern was identified for one (1) of four (4) tube feeding site care observations.

Inspectors wroteBased on observation, record review, facility policy review, and staff interview, the facility failed to assess and evaluate Resident #61's need for assistive devices to assist with eating. This concern was identified for one (1) of eleven (11) residents assessed for nutrition.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to notify the Resident Representative in writing of a transfer to an acute care hospital for one (1) of three (3) residents reviewed for hospitalizations, Resident #87.