Ocean Springs Health & Rehabilitation Center

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to revise Resident #1's comprehensive, person-centered care plan to include individualized interventions for physician-ordered wound care for one (1) of three (3) residents reviewed for care planning, Resident #1.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to provide treatment and services in accordance with professional standards of practice by failing to timely transcribe physician-ordered wound care into the resident's medical record and failing to document physician-ordered wound treatments in the clinical record for one (1) of three (3) residents reviewed for wound care (Resident #1).

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain food quality and hygienic practices in accordance with professional standards for food safety related to overly ripened produce, improperly stored food, exposed food, expired food, and unsanitary handling of ready-to-eat food for two (2) of (2) kitchen observations.

Inspectors wroteBased on record review and interview, the facility failed to accurately report staffing data to the Centers for Medicare and Medicaid Services (CMS) using payroll and other verifiable sources in a uniform format, for one (1) of four (4) quarters reviewed, FY (Fiscal Year) Quarter 3 2025 (April 1-June 20) resulting in the facility triggering for excessively low weekend staffing, no Registered Nurse (RN) hours, and no licensed nursing coverage 24 hours/day.

Inspectors wroteBased 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 the recurrence of previously cited deficiencies, specifically, the facility was cited for failing to accurately submit direct care staffing information and failed to ensure the QAPI program was sustained during transitions in leadership to maintain implemented procedures during an annual recertification survey on 4/18/24 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for two (2) of (11) deficiencies cited. F851 and F865/867. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to dignity and respect when staff required her to wear a brief against her preference instead of providing a bedpan or assistance to the bathroom for one (1) of (22) sampled residents, Resident #109.

Inspectors wroteBased on interviews and record review, the facility failed to honor a resident's request for assistance in obtaining personal identification, resulting in a delay of more than one (1) year without follow-up affecting her autonomy and ability to exercise her rights related to personal identification and community access for (1) of (22) sampled residents, Resident #48.

Inspectors wroteBased on record review, interviews, and resident council interview, the facility failed to provide residents or their resident representatives (RRs) with copies of the Resident [NAME] of Rights and admission documents at the time of admission, with the potential to affect all newly admitted residents by depriving them of required information about their rights and responsibilities upon admission for one (1) of 22 sampled residents (Resident #26).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to personal privacy by posting identifying hospice information on a resident's door for one (1) of 22 sampled residents. Resident #85.

Inspectors wroteBased on staff interview, record review, facility investigation and facility policy review, the facility failed to implement its abuse prevention policy by not reporting and investigating an allegation of misappropriation of resident property in a timely manner for one (1) of 22 sampled residents, Resident #106. Findings Include:A review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation, revised 11/16/2022, revealed, .7. Reporting/Response: Any employee or contracted service provider who.has knowledge of.an allegation of.misappropriation of resident property.is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs) for residents who are dependent upon staff, related to incontinence care (Resident #109) and shaving (Resident #91) for two (2) of 22 sampled residents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not implementing contact isolation precautions timely for (Resident #47) and enhanced barrier precautions (EBP) when providing care for (Resident #4) for two (2) of 22 sampled residents.

Inspectors wroteBased on observation and staff interview, the facility failed to post daily nurse staffing information in a prominent place readily accessible to residents, staff, and visitors for four (4) of (4) days of survey, which had the potential to affect all 108 residents residing in the facility.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide incontinence care in a timely manner for six (6) of 22 sampled residents and resulted in Resident #57 having skin excoriations and Resident #55 free from wearing two (2) incontinence briefs with a current diagnosis of Urinary Tract Infection (UTI). (Residents #57, #55, #1, #8, #14, and #38)

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to accurately submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for Quarter 1 of Fiscal Year (FY) 2023 (October - December 2023) for one (1) of five (5) quarters reviewed.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right for a dignified dining experience when the staff did not provide incontinence care for a resident which resulted in odors in the resident's room, causing the meal to be unappetizing, for one (1) of 22 sampled residents.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to develop care plan interventions for a resident with a Urinary Tract Infection (UTI) (Resident #55) and for a resident with Substance Use Disorder (SUD) (Resident #57), and failed to implement a care plan intervention related to a low air loss mattress (Resident #261) for three (3) of 22 resident care plans reviewed.

Inspectors wroteBased on interviews and record review the facility failed to ensure a resident's safety by not assessing for the risk of substance use and not developing interventions for a resident with known substance use disorder (SUD) for one (1) of 22 sampled residents. (Resident # 57)

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to ensure the program was sustained during transitions in leadership and failed to maintain implemented procedures and monitor the interventions the committee put into place in April 2022. This was for two (2) recited deficiencies originally cited in April 2022 on an annual recertification survey. The deficiencies were in the area of residents' rights and wounds. The facility's continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee for two (2) of eight (8) deficient practice citations. Findings Include: A record review of the facility's policy, Quality Assurance Performance Improvement Program (QAPI), with a revision date of 10/24/2022, revealed, Policy: [...]

Inspectors wroteBased on observation, staff interview and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by a nurse touching medications with her bare hand and Certified Nursing Assistants (CNAs) discarding soiled linens and briefs on the floor for three (3) of nine (9) medication and incontinence care observations.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a Pressure Ulcer (PU) intervention related to an air mattress was continued after a room change for one (1) of three (3) residents reviewed for PUs.

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to treat a resident in a dignified manner by not covering the resident during incontinence/catheter care for one (1) of eight (8) care observations. (Resident #77) Review of the facility's Policies and Procedures with the Subject of Perineal Care with a revised date of 9/5/2017 revealed, Procedure .Remove necessary clothing .Wash, rinse and dry the skin, being certain to expose all skin surfaces which are soiled . On 04/26/22 at10:07 AM, the State Agency (SA) observed incontinent/catheter care with Certified Nursing Assistant (CNA) #8 for Resident #77. Her husband remained in the room for the procedure. CNA #8 pulled the residents gown up, pulled the cover down, and exposed her perineal area. CNA #8 then went to the sink and filled the water basin, leaving the resident exposed. [...]

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to resolve a resident's grievance regarding personal property for one (1) of three (3) residents reviewed for misappropriation of property. Resident #20. Record review of the facility's Clinical Guideline - Complaint/Grievance with a revision date of 8/9/2018, revealed, .Purpose: To support each resident's right to voice grievances; resulting in a follow-up and resolution while keeping the resident apprised of its progress toward resolution .Process . The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days . The individual voicing the grievance shall receive follow up communication with the resolution . Record review of Resident #20's admission Record revealed he was admitted by the facility initially on 7/30/21 and had a recent re-admission date of 1/11/22. [...]

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to thoroughly investigate a resident's allegation of misappropriation of personal property for one (1) of three (3) residents reviewed for misappropriation of property. (Resident #20) Record review of the facility's policy, Protection of Resident's Personal Property, (undated) revealed, Policy .6. The Administrator or his/her designee will log the missing items, complete an investigation on all missing items and document results of findings .The Administrator will ensure that the resident/ responsible parties informed of the results of the investigation . On 04/25/22 at 03:00 PM, Resident #20 stated that he was missing a gold ring with three diamonds in it. He put his ring in the bedside nightstand in the drawer and the end of last year (2021) and it was gone when he went to look for it. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to ensure residents who were dependent on staff for showering, shaving, and nail care received those services for five (5) of six (6) residents reviewed for Activities of Daily Living (ADLs) assistance. Resident #48, Resident #49, Resident #56, Resident #58, and Resident #60. Review of the faciality's Policies and Procedures with the Subject of Bathing/Showering, revised on 9/1/2017, revealed Policy: Assistance with showering and bathing will be provided at least twice a week and PRN to cleanse and refresh the resident. The resident shall be asked on admission to establish a frequency schedule for bathing. This schedule will take precedence over the twice a week and PRN cleansing . [...]

Inspectors wroteF686 Based on observation, interview, record review and facility policy review the facility failed to clean a residents wound according to professional standards for two (2) of four (4) wound care observations Resident #49 and Resident #63.

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to prevent a significant medication error when a resident did not receive sliding scale insulin per physician's orders for one (1) of two (2) residents reviewed. Resident #234.

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed remove expired food items from the pantry, failed to date open food items and failed to reseal a hamburger bun package for one (1) of three (3) kitchen observations. Record review of the Facility's Policies and Procedures with the Subject as Dry Food Storage, dated 11/30/2014, revealed, Policy: To prevent damage, infestation and spoilage of food and maintain quality food products .Procedure: . Open packages will be stored in closed containers or secured with metal ties, etc. and dated . On 04/25/22 at 010:30 AM, an initial observation of the kitchen with the Regional Dietary Director (RDD) revealed a bag of hamburger buns torn open and exposed to air on the bread cart. There were 2 containers of thickened apple juice with expiration dates of 4/12/22 and 4/15/22. [...]