Singing River Skilled Nursing Facility

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent a fall for one (1) of five (5) sampled residents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure Resident #1's right to be free from physical abuse from a staff member for one (1) of four (4) sampled residents. Resident #1 Resident #1 was physically abused on 12/17/24 when the Campus Police Officer (CPO) #1 hit the resident with his own shoe, pushed the resident to the floor, and attempted to use a taser improperly. (4) nurses observed the abuse and failed to intervene, allowing the abuse to escalate. This resulted in Resident #1 receiving a hematoma. The facility's failure to protect Resident #1 from abuse caused physical harm, including a hematoma requiring an emergency room evaluation. Additionally, the facility's failure to intervene placed other residents at risk for similar abuse. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for a resident with behaviors for one (1) of four (4) sampled residents. Resident #1 On 12/17/24, when Resident #1 exhibited behaviors, staff failed to implement care plan interventions. Instead, a nurse called the Campus Police Officer (CPO) who physically abused the resident by hitting the resident with their own shoe, pushing the resident to the ground, and attempting to use a taser. The facility's failure to implement the care plan interventions directly resulted in Resident #1, sustaining a hematoma on the head and the need for emergency medical evaluation. Additionally, the facility's failure placed other residents at risk as staff did not follow prescribed actions to manage behaviors and ensure resident safety. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement care plan interventions related to a latex allergy which resulted in a resident having a topical allergic reaction treatment for one (1) of 12 care plans reviewed. (Resident #12) Resident #12. Findings Include: Review of the facility's policy, Nursing Assessment and Plan of Care, dated 3/2021, revealed, .Skilled Nursing Facility A. All patients are observed upon admission by a licensed nurse. The initial observation includes: 1. Essential patient history including allergies .Plan of Care A. The nurse analyzes the assessment date in order to identify and prioritize problems to be addressed when developing the plan of care. B. The plan of care .specifies the approach to an individual patient's physiological, psychological, cognitive or education needs. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent complications when facility staff inserted a latex catheter for a resident with a known latex allergy that resulted in the resident having a topical allergic reaction for one (1) of two (2) residents reviewed for bowel/bladder and catheters. Resident #12 Findings Include: A review of the facility's policy titled Urinary Catheter Clinical Practice Guideline, dated 7/2020, revealed, .Insertion of Indwelling Urinary Catheter .Procedure .2. Verify any allergies to latex, iodine, or betadine - if latex allergy: consider silicone catheter . [...]

Inspectors wroteBased on interviews and record review, the facility failed to offer assistance in formulating an advance directive and did not document discussions related to the resident's right to formulate and establish an advance directive for six (6) of twelve (12) residents reviewed for advance directives, with the potential to affect all 27 residents residing the in the facility. (Residents #1, #7, #9, #11, #222, and #223). Findings Include: Resident #1 A record review of Resident #1's Patient Information revealed the resident was admitted on [DATE] with diagnoses including Paroxysmal Atrial Fibrillation and Type 2 Diabetes Mellitus. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24 revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure there was sufficient staff to meet the needs of residents in a timely manner for four (4) of nine (9) residents observed with call lights on, needing assistance on the Northeast Hall. (Residents #69, #220, #221, and #223). This failure had the potential to affect all nine (9) dependent residents residing on the hall. Findings Include: A review of the facility's Facility Assessment Tool, updated on 1/31/2024, revealed . Staffing plan: 3.2 .Consider if and how .acuity levels impact staffing needs. To provide care for nine (9) residents, the facility required one (1) Registered Nurse (RN) or one (1) Licensed Practical Nurse (LPN) and one (1) Certified Nursing Assistant (CNA). This ratio on (1) employee per (9) residents (1:9) was the requirement for both days and nights. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to a dignified existence related to a urinary catheter drainage bag which did not have a privacy bag for one (1) of two (2) residents reviewed for bowel/bladder and catheters. (Resident #12) Findings Include: A review of the facility's Patient Rights and Responsibilities Policy, dated 2/2024, revealed, (Proper name of facility) is committed to upholding and respecting the rights of our patients. This policy outlines .commitment to providing considerate care that respects cultural, psychosocial, spiritual, and personal values, beliefs, and preferences .Patient Rights: You have a right to 1. Considerate care, including respect for your cultural, psychosocial, spiritual, and personal values, beliefs and preferences . [...]

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to store food and maintain sanitary practices in accordance with professional standards for safety related to foods not labeled, food with no identified date, exposed foods and unsanitary practices staff for one (1) of two (2) kitchen observations.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment for three (3) of 15 residents sampled. Resident #4, Resident #5, and Resident #7 Findings Include: A review of the facility's policy MDS Completion and Submission Timeframes, with a revision date of 03/01/2022, revealed, . Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted . in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . [...]