Yazoo City Rehabilitation and Healthcare Center

Inspectors wroteBased on record review, staff and resident representative interview, and facility policy review, the facility failed to implement an effective discharge planning process to ensure necessary durable medical equipment (DME) was arranged and received prior to discharge for one (1) of three (3) residents reviewed, Resident #1. The facility failed to ensure Resident #1, who required tracheostomy care including suctioning and nebulizer treatments, was discharged with necessary respiratory equipment. The resident was discharged home on 2/23/26 without a suction machine or nebulizer, resulting in the need for emergency medical services (EMS) intervention and subsequent hospitalization due to unsafe discharge conditions. The facility's failure to ensure a safe discharge process placed Resident #1 in a situation that was likely to cause serious harm, injury, impairment, or death. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to ensure the physician or nurse practitioner was notified of an omitted medication for one (1) of three (3) residents reviewed for medication errors. Resident #2. Findings Included:Record review of the facility policy, titled Condition & Medical Doctor (MD)-Family Notification, revealed Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories. A need to significantly alter treatment. Record review of Order Summary Report for Resident #2 revealed an order for Lantus SoloStar Subcutaneous Solution Pen-Injector 100 units/milliliter. Inject 10 units subcutaneously at bedtime with an order date of 1/16/26. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to administer ordered Lantus insulin for three (3) consecutive days for one (1) of three (3) resident reviewed for medication errors. Resident #2 Findings Included:Record review of the facility policy titled, Medication Administration reviewed and revised 3/5/26 revealed 4. Medications are administered according to prescriber orders and within the ordered time frames. Record review of Order Summary Report for Resident #2 revealed an order for Lantus SoloStar Subcutaneous Solution Pen-Injector 100 units/milliliter. Inject 10 units subcutaneously at bedtime with an order date of 1/16/26. Record review of the January 2026 Medication Administration Record (MAR) for Resident #2 revealed that on 1/16/26, 1/17/26, and 1/18/26, the resident did not receive the ordered dose of insulin. [...]

Inspectors wroteBased on observation, resident and staff interview, and facility policy review, the facility failed to provide incontinence care in accordance with the resident's care plan for one (1) of 10 residents reviewed for activities of daily living (ADLs). Resident #1Findings Include:Record review of the facility policy titled Activities of Daily Living, Supporting revealed Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.in accordance with the plan of care.including appropriate support and assistance with: c. elimination (toileting). [...]

Inspectors wroteBased on observation, resident and staff interview, and facility policy review the facility failed to provide Activities of Daily Living (ADL) assistance to a dependent resident related to incontinent care for one (1) of 10 residents reviewed for ADLs. Resident #1. Findings Include:Record review of the facility policy titled Activities of Daily Living, Supporting revealed Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.including appropriate support and assistance with: c. elimination (toileting). [...]

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to update a care plan after a residents falls for one (1) of three (3) resident care plans reviewed. Resident #1 Findings Include A review of the facility policy titled, “Fall Prevention Program,” revealed “All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter…The resident's plan of care will be updated to reflect risk for falls and appropriate interventions… If a fall occurs… the plan of care will be updated to reflect interventions.” A record review of the “Care Plan Report” for Resident #1 revealed a focus of “The resident is at risk for falls related to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left dominant side, Hypertension, and blindness.” Interventions [...]

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to ensure effective supervision and accident prevention interventions were in place to mitigate the risk of falls for one (1) of three (3) residents reviewed for accidents (Resident #1). This deficient practice resulted in the resident sustaining a fall with a laceration and hematoma to the left eyebrow, requiring emergency department treatment. Top of Form Findings Include A review of the facility policy titled, “Fall Prevention Program,” review date 6/18/25 revealed: “All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. [...]

Inspectors wroteBased on resident and staff interviews, facility investigation review, record review and facility policy review, the facility failed ensure a residents right to be free from misappropriation for one (1) of five (5) residents reviewed for misappropriation of resident funds, Resident #2. A Certified Nursing Assistant (CNA) misappropriated money from the resident's trust fund account and Cash App account. Findings Include Findings Include Review of the facility policy titled Abuse Prohibition Policy latest review date 6/2/25, revealed, Intent . Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse .The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of resident property or finances of residents . [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review the facility failed to implement a care plan related to implementing Enhanced Barrier Precautions (EBP) (Resident #20) and performing activities of daily living (ADL) (Resident's #38 and #80) for three (3) of 30 resident care plans reviewed.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide the necessary services to maintain grooming and personal hygiene for residents who are unable to self-perform activities of daily living (ADL's) for (2) two of 161 residents observed for ADL's. (Resident # 38 and #80)

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review, the facility failed to provide a resident with a dignified existence as evidenced by leaving a urinary catheter bag uncovered for one (1) of five (5) sampled residents with urinary catheters. Resident #20. Findings Include: Review of the facility policy titled, Protocol for Keeping Catheter Bags Covered for Dignity Purposes in a Nursing Home with no revision date revealed under Objective .To maintain the dignity, privacy, and comfort of residents with catheter bags by ensuring that catheter bags are properly covered . 2. Proper Covering of Catheter Bags .Catheter bags should be covered with an appropriate, discreet cloth or garment. [...]

Inspectors wroteBased on observation, staff and resident interview, and facility policy review, the facility failed to ensure a call light device was accessible for a dependent resident for one (1) of 32 sampled residents.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to resolve grievances related to missing clothes items for four (4) of six (6) residents in the resident council meeting. Resident #15, Resident #115, Resident #124, and Resident #126.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure a resident's code status was accurate in the physician orders for one (1) of 40 residents reviewed for advanced directives during initial pool. Resident #135 Findings Include: The facility provided a statement on letterhead signed by the Administrator that read, This facility does not have a policy for discrepancies between advance directive and physician order. Record review of Resident #135's Consent for Cardiopulmonary Resuscitation (CPR) dated, [DATE] revealed, Decline CPR: I understand that CPR constitutes an extraordinary measure and SHOULD NOT be performed was checked and signed by Resident #135's family member. Record review of Resident #135's Physician Order Detail revealed an order dated [DATE], CPR (Cardiopulmonary Resuscitation). [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment for two (2) of three (3) survey days.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to monitor a resident receiving anticoagulant medication for signs of bruising and bleeding for one (1) of five (5) residents reviewed for unnecessary medication.

Inspectors wroteBased on observation, staff interviews, and facility policy review the facility failed to ensure the proper storage of drugs as evidenced by a medication cart being left unlocked during medication administration for one (1) of four (4) medication carts observed. Findings Include: Record review of the facility policy titled Storage of Medications with reviewed date of July 2024 revealed under policy statement, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .9. Unlocked medication carts are not left unattended An observation on 11/13/24 at 8:20 AM, revealed Licensed Practical Nurse (LPN) #3, administer medications to a resident in room [ROOM NUMBER]. LPN #3 left the medication cart outside of room [ROOM NUMBER] with the medication drawers facing the outside of the door. [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review the facility failed to ensure that Enhanced Barrier Precautions (EBP) was implemented for a resident that required EBP for (1) of five (5) direct care areas observed. Findings Include: Record review of the facility policy, Enhanced Barrier Precautions (EBP) dated 04/01/24 revealed that EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected . The policy also revealed that gloves and gowns are to be donned when performing wound care. An observation on 11/13/24 at 11:20 AM, revealed Licensed Practical Nurse (LPN) #4, completed wound care to Resident #20's left heel without donning a gown prior to the wound care being performed. LPN #4 revealed that she knew to use EBP with wound care, but she got nervous and forgot. [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to monitor frequently and have provided increased supervision to a resident who was identified by the facility as being at high risk for wandering for one (1) of seven (7) residents at risk. (Resident # 73). Findings Include: Record review of the facility policy titled, Wander Management Monitoring System and Resident Elopement Protocol, with a revision date of 1/17/18 revealed, Purpose: To monitor safety of residents at risk for elopement . Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible . [...]

Inspectors wroteBased on staff interviews, resident interviews, observations, record reviews, and facility policy and procedure reviews, the facility failed to provide supervision to prevent the elopement of a delusional resident who voiced and was identified by the facility as being at high risk for elopement. Resident #1 was one (1) of six (6) Residents that the facility had identified as at risk for elopement. (Resident #1) The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) Past Non-Compliance (PNC) which began on [DATE], when the facility allowed Resident #1 to leave the facility through his disassembled bedroom window unsupervised and unwitnessed. Resident #1 was found several miles away by local Law Enforcement at a store. He was assumed by the facility to be away from his bedroom for approximately five and a half (5.5) hours. [...]

Inspectors wroteBased on dialysis center staff interviews, facility staff interviews, resident interview, record review, and facility policy review, the facility failed to ensure the right to be free from neglect when the facility failed to transport a dialysis resident to a scheduled surgical procedure to ligate (to tie up or close off an artery) an arteriovenous (AV) fistula scheduled on 03/21/24 resulting in the resident being admitted to the hospital on [DATE] with a bleeding aneurysm of the AV fistula requiring a blood transfusion with (4) four units of blood for one (1) of four (4) residents on dialysis reviewed. (Resident #2) The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 03/21/24, when the facility neglected to transport Resident #2 to his appointment for a scheduled surgical procedure. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to revise the care plan for a severely cognitively impaired resident who eloped from the facility for one (1) of nine (9) sampled residents. (Resident #1) The SA identified an Immediate Jeopardy (IJ) which began 3/31/24 when the facility allowed Resident #1 to exit the facility unsupervised and was found approximately eight-tenths of a mile from the facility by police. He was away from the facility for 81 minutes. The facility's failure to provide supervision resulted in elopement and places cognitively impaired residents at risk, and in a situation which was likely to cause serious injury, harm, impairment, or death. On 4/3/24 at 5:31 PM, the SA informed the Nursing Home Administrator (NHA) of the Immediate Jeopardy (IJ) and provided the IJ Template. [...]

Inspectors wroteBased on staff and resident interviews, record review and facility policy review, the facility failed to provide supervision to prevent the elopement of a resident who was severely cognitively impaired for one (1) of five (5) residents reviewed. Resident #1. The facility failed to provide supervision to prevent the elopement of Resident #1, who was severely cognitively impaired and left the facility unattended. This failure allowed Resident #1 to be away from the facility unnoticed and unsupervised on 3/31/24 from 7:25 PM until 8:41 PM, when the facility was alerted that the resident was seen in the community, approximately eight-tenths (0.8) of a mile from the facility. This was approximately 81 minutes after Resident #1 was last observed in the facility. [...]

Inspectors wroteBased on staff interviews, record review, staff schedule and facility policy review the facility: 1) failed to protect the residents right to be free from neglect as evidenced by failure to ensure nursing staff provided supervision and nursing services to 25 residents of 146 residents who resided in the facility when a nurse failed to report for duty for the 11:00 PM to 7:00 AM shift on 1/27/24, which resulted in 14 residents not receiving medications. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to report to the State Survey Agency that there was no licensed nurse available for 25 residents of 146 residents residing in the facility on the 11:00 to 7:00 shift on 1/27/24. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 1/27/24 when a licensed nurse failed to report for duty and the facility failed to find a replacement. Fourteen residents did not receive their 6:00 AM medications on the 11 PM to 7:00 AM shift on 1/27/24, related to no licensed nurse assigned to the Annex A medication cart. Twenty-five residents did not receive monitoring or supervision. [...]

Inspectors wroteBased on care plan review, record review, facility policy review, and staff interview, the facility failed to implement a comprehensive care plan related to medication administration for 14 of 25 residents reviewed for care plans. The facility's failure to implement care plans, placed the residents at risk, and in a situation that was likely to cause serious injury, harm, impairment, or death. On 2/2/24, the State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 1/27/2024, with the facility's failure to provide a licensed nurse to implement comprehensive care plans resulted in 14 residents not receiving medications per physician's orders. On 2/02/24 at 12:20 PM, the SA informed the Nursing Home Administrator (NHA) of the IJ and provided the Administrator with the IJ Templates. [...]

Inspectors wroteBased on facility policy review, record review, resident and staff interviews, the facility failed to provide: 1. sufficient qualified nursing staff to provide nursing related services to assure resident safety, as evidenced by failure to ensure a licensed nurse was present to administer medications, and monitoring for 25 of 52 residents on the Annex Hall from 11:35 PM on 1/27/24 to 7:00 AM on 1/28/24. and 2. failed to ensure sufficient staff to provide care and services for two (2) of 22 residents reviewed. The Licensed Practical Nurse (LPN) who was scheduled to report at 7:00 PM on 1/27/24 did not arrive for her shift at the facility. Licensed Practical Nurse (LPN) #1 had worked since 7:00 AM and left the facility at 11:35 PM without on-site licensed nurse relief present. [...]

Inspectors wroteBased on staff interviews, resident interviews, facility policy review, and record review the facility failed to ensure significant medications were administered to prevent discomfort or complications for four (4) of 14 residents reviewed with medication errors. This resulted in significant medication errors for Resident #1, Resident #3, Resident #4, and Resident #5. The facility did not have licensed nurse coverage for twenty-five (25) residents on the Annex A Hall of the facility for eight (8) hours from 11:00 PM through 7:00 AM on 1/27/24. Resident #1 Resident #3, Resident #4, and Resident #5 had scheduled medications to be administered at 6:00 AM. The significant medications which were missed included anti-coagulants, anti-seizure, anti-diabetic (insulin), diuretic, and pain management medications. [...]

Inspectors wroteBased on facility policy review, record review, staff interviews, and resident interviews the facility administration failed to use its resources effectively and efficiently to ensure licensed staff was available to provide care for twenty-five (25) of (53) residents on the Annex Unit with for eight (8) hours on 1/27/24 from 11:00 PM through 7:00 AM on 1/28/24. The Licensed Practical Nurse (LPN) who was scheduled to report at 7:00 PM on 1/27/24 did not arrive for her shift at the facility. LPN #1 had worked since 7:00 AM and left the facility at 11:35 PM on 1/27/24. LPN # 2 counted the narcotic cart for Annex A hall and took the keys to the cart but did not accept responsibility for the twenty (25) residents on the Annex A hall of the facility. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review the facility failed to ensure residents received appropriate care and services to promote continence for residents requiring assistance with bowel and bladder care for (2) two of 22 residents reviewed. (Resident # 1 and Resident #8) Findings Include: Record review of the facility policy Urinary Continence and Incontinence- Assessment and Management revised August 2022, revealed Policy Statement: 1. The staff and the Practitioner will appropriately screen for, and manage, individuals with urinary incontinence .Policy Interpretation and Implementation .18b. Incontinence care should be individualized at night in order to maintain comfort and skin integrity . [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to properly thaw raw chicken for meal preparation for one (1) of three (3) kitchen tours. Findings Include Review of the facility policy titled, Food: Preparation, with a revised date of 9/2017, revealed Policy Statement: All foods are prepared in accordance with the FDA Food Code. Procedures: . 5. The [NAME] (s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: . Completely submerging the item under cold water (at a temperature of 70 degrees F (Fahrenheit) or below) that is running fast enough to agitate and float off loose ice particles. An observation, during the initial tour, on 08/14/23, at 10:14 AM revealed a clear bag containing raw chicken in a metal strainer in the double-sided sink to thaw. [...]

Inspectors wroteBased on observations, resident and staff interview, record review and facility policy review the facility failed to honor the choices of residents for not serving food preferences (Resident #65), not serving double portions (Resident #105) and for not being assisted out of bed (Resident #49 and 123) for four (4) of 139 resident's reviewed during survey.

Inspectors wroteBased on observation, staff and resident interviews, record review and facility policy review the facility failed to develop a comprehensive care plan for a resident who wanders (Resident # 85) and failed to implement a care plan for a resident who required assistance for activities of daily living (ADL), Resident #22 and #127, for three (3) of 28 comprehensive care plans reviewed. Findings Include: A record review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revealed Policy Statement, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. [...]

Inspectors wroteBased on observations, staff and resident interview, record review and facility policy review the facility failed to assist a resident out of bed and provide nail care for resident's that require assistance with Activities of Daily Living (ADLs) for two (2) of 139 residents reviewed during survey. Resident #22 and #127.

Inspectors wroteBased on observation, resident and staff interview, record review and a facility policy, the facility failed to provide adequate supervision in order to reduce the risk of an accident hazard for two (2) of 139 residents reviewed in the facility. Resident #29 and 85.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review the facility failed to post oxygen in use signage outside the resident's room entrance door for one (1) of 15 residents reviewed receiving oxygen. Resident #290 Findings Include Review of the facility policy titled, Oxygen Administration, with a revised date of February 2023, revealed, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure . 2. Place an Oxygen in Use sign on the outside of the room entrance door. 3. Place an Oxygen in Use sign in a designated place. An observation on 08/14/23 at 11:23 AM, with Resident #290 revealed there was no oxygen (O2) signage outside the room entrance door. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to provide a stop date for a psychotropic medication ordered as needed (PRN) for one (1) of four (4) residents reviewed for psychotropic medication review.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to prevent the likelihood of food-bourne illness as evidenced by a dietary staff member who dropped an individual sweetener packet on the floor and returned it to the clean collection of packets and then placed them on the resident trays for one (1) of six (6) kitchen tours.

Inspectors wroteBased on staff interview, facility policy review, and record review the facility failed to obtain a follow-up Preadmission Screening and Resident Review (PASRR) for a resident with a new psychiatric diagnosis for one (1) of two (2) residents reviewed for PASRR. Resident #70.