Trend Health and Rehab of Natchez, LLC

Inspectors wroteBased 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.

Inspectors wroteBased 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.

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 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)

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteResident #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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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)

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to discard 30 cartons of chocolate milk that expired on 9/11/23 for one (1) of four (4) days of observations of the kitchen.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staff interview, record review and policy review the facility failed to maintain the kitchen in a clean and sanitary condition as evidenced by not cleaning the thermometer during tray line temps, and failure to have the dishwasher at recommended water temperatures for two (2) of three (3) kitchen observations.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) related to anticoagulants for one (1) of 22 resident MDS assessments reviewed, Resident #49.

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was completed accurately to reflect Resident #40's diagnosis of a Major Mental Illness, for one (1) of 22 residents reviewed.

Inspectors wroteBased on observation, staff interview, resident interview, record review, and facility policy review, the facility failed to revise care plan related to dialysis treatment for Resident #63, and anticoagulant use for Resident #25, for two (2) of 22 resident care plans reviewed.