Sharkey-Issaquena Nursing Home

Inspectors wroteBased on interview, record review, and consultant pharmacist job description review the facility failed to ensure a monthly medication regimen review (MMR) was conducted by the consultant pharmacist for residents residing in the facility for twelve (12) of (12) months reviewed, with the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to submit Payroll-Based Journal (PBJ) staffing data to the Centers for Medicare & Medicaid Services (CMS) for one (1) of (1) quarter reviewed. (Fiscal Year Quarter 2 2026)

Inspectors wroteBased on staff interview, record review, and admission Package review, the facility failed to ensure residents or their Resident Representatives (RRs) were informed of their rights regarding Advance Directives (ADs), including whether an AD existed and whether they wished to receive information or assistance in formulating an AD, for two (2) of (16) sampled residents. Resident #11 and Resident #22.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to personal privacy for one (1) of (16) sampled residents reviewed for resident rights, as evidenced by posting of identifying personal care directions including Nothing by Mouth (NPO), Keep Head of Bed (HOB) elevated at 45 degrees, safe swallow precautions, and elevate my legs while in bed. Resident #33.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure Resident #34's right to have grievances investigated and resolved by failing to initiate the grievance process after the resident reported three (3) missing clothing outfits for one (1) of (16) sampled residents reviewed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical restraints by failing to identify a self-releasing seat belt as a restraint for one (1) of (16) sampled residents, Resident #21, who was unable to independently release the device.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed and coded in accordance with MDS requirements for three (3) of (16) sampled residents reviewed for MDS accuracy, as evidenced by failing to complete discharge assessment and entry assessments (Resident #2 and Resident #56) and inaccurately coding Resident #55's MDS to indicate Death in Facility when the resident expired at the hospital.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to develop a comprehensive, person-centered care plan related to hospice services for Resident #41 and for all care and services for Resident #42 for two (2) of (16) sampled residents.

Inspectors wroteBased on interviews, record review, and the facility policy review the facility failed to revise a resident's care plan for two (2) of (16) sampled residents related to significant weight loss and pressure injuries (Resident #2) and changes in psychotropic medication (Resident #13).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure smoking and vaping activities were assessed, supervised, and conducted in accordance with facility policy and resident safety requirements for one (1) of three (3) residents reviewed for accident/hazards. (Resident #51).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident with bed rails had an entrapment assessment and consent completed for the use of bed rails for one (1) of (16) sampled residents. Resident #42.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure that all required members participated in the facility's Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement (QAPI) meetings, as evidenced by the absence of the Medical Director from five (5) of (5) QAPI meetings reviewed.

Inspectors wroteBased on observations, staff interviews, record reviews, and facility policy review, the facility failed to check and record food temperatures before serving all meals for the last 30 of 30 days. Findings Included: A review of the facility's policy titled Monitoring Temperatures of Cooked Foods revealed, Policy: The temperature of potentially hazardous cooked foods will be monitored to ensure that the foods are not in the danger zone (above 41 degrees F (Fahrenheit) and below 135 degrees F) for more than six hours . Cooking, holding, and storage temperatures should be recorded on a Food Temperature Monitoring Log. These logs should be maintained for at least three (3) months. During an observation of the kitchen on 10/2/24 at 11:35 AM, it was noted that kitchen staff were serving lunch to the dining room residents from the steam table. [...]

Inspectors wroteBased on record reviews, staff interviews, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to prevent the transmission of communicable diseases and infections. This failure was evidenced by the facility's failure to administer a second-step tuberculin (TB) skin test to one (1) of 17 residents (Resident #104) and 34 of 37 employees, who had no documentation of a negative TB skin test within the last 12 months. Findings Include: A review of the facility's policy titled TB Testing MS, with a revision date of 4/14, stated: Resident Testing for Tuberculosis .Residents .shall have a baseline Tuberculin Skin Test (TST) performed with the initial step of a two-step Mantoux TST placed within 30 days prior to the day of admission. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to conceal the urine collection bag for a resident's indwelling urinary catheter, thus failing to maintain the dignity of a resident, for one (1) of two (2) residents with urinary catheters. (Resident #51). Findings Include: A review of the facility's policy titled Resident Rights revealed, It is the policy of this facility to ensure that the rights of the residents residing at this facility are upheld in the highest regard . 2. Each resident has the right to a dignified existence . During observations on 10/01/24 at 10:50 AM and 1:28 PM, it was noted that Resident #51's door was open, and an indwelling catheter bag was visible hanging on the side of the bed, without a privacy cover. [...]

Inspectors wroteBased on record review, staff interviews and facility policy review, the facility failed to accurately complete and request a Preadmission Screening and Resident Review (PASARR) for a resident with a history of mental illness for one (1) of 12 residents reviewed. Resident #106 Findings Include: Record review of the facility policy titled, Pre-admission Screening PAS/PASRR with a revision date of 6/13 revealed under, Level II PASRR . When Level 1 screening on the PAS (Preadmission Screening) indicates possible Mental Illness or Intellectual Disability/Developmental Disability and related conditions (RC) the DOM (Division of Medicaid) will notify Proper Name to review the case. Record review of the Level 1 PAS (Pre admission Screening) for Resident #106, with a submission date of 9/30/24, revealed under, Referral Question #28. [...]

Inspectors wroteBased on observations, record review, interviews and facility policy review, the facility failed to provide adequate care and treatment to a pressure ulcer to improve healing for Resident #104, for one (1) of 1 resident reviewed for pressure ulcers. Findings Include: Review of the facility policy titled Wound Care with a revision date of 10/2/24 revealed under, Purpose: To provide standardized procedures for the prevention, identification, treatment, and ongoing management of wounds, ensuring the highest quality of care for all residents while maintaining compliance with local, state, and federal regulations . Also revealed under, a. Treatment Plan - A treatment plan will be developed by the wound care team and documented in the resident's medical record. This plan may include: - Cleansing and dressing the wound. - Use of appropriate topical medications or advanced wound care products . [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure a resident receiving an as needed (PRN) psychotropic medication had a stop date for one (1) of two (2) medication reviews. Resident #108 Findings Include: Review of the facility policy titled Psychotropic Medications for PRN (as needed) Use and Gradual Dose Reduction (GDR) Reviews undated, revealed under, Policy: . PRN use of psychotropic medications will be strictly regulated and monitored to comply with CMS (Centers for Medicare and Medicaid Services) regulations and ensure resident safety .Time Limitation: PRN orders for psychotropic medications must be limited to 14 days. After 14 days, the attending physician must review the resident's condition before extending the PRN order for continued use. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to label and date food stored in the refrigerator and freezer for one (1) of two (2) kitchen tours.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to develop a care plan for anticoagulant medication for two (2) of 12 resident care plans reviewed, Residents #24 and #34.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to prevent the likelihood of infection, during medication administration, for one (1) of three (3) of six (6) residents observed for medication administration.