Ocean Springs Health & Rehabilitation Center

Penalty

Inspection fine: $10,361

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement care plan interventions for a resident identified as an elopement and wandering risk. On February 8, 2025, at approximately 3:00 PM, the resident exited the facility unsupervised while wearing a wander alarm device that was found to be inoperable. The resident was out of the facility for about thirty minutes and walked approximately 0.7 miles, crossing a four-lane highway before being located by facility staff and returned to the facility. The care plan for the resident included interventions to ensure the wander guard was functioning properly daily, with the responsibility assigned to the nursing staff. However, interviews revealed that the Licensed Practical Nurse (LPN) on duty did not check the functionality of the wander guard transmitter, only verifying its placement. This oversight was a critical lapse in following the care plan, which was designed to prevent elopement and ensure the resident's safety. The resident had been admitted to the facility with diagnoses including aphasia following cerebral infarction, cognitive communication deficit, and legal blindness. The Minimum Data Set (MDS) assessment indicated severe cognitive impairment, with long and short-term memory problems and impaired decision-making skills. Despite these known risks, the failure to monitor the wander guard's functionality as per the care plan led to the resident's unsupervised exit, putting them at risk for serious harm.

Removal Plan

• Resident was assessed upon return to the facility and had no injuries, the wander guard device was found to be inoperable, and Resident was placed on one-on-one supervision.
• The facility reviewed the wandering/missing resident policy, educated staff on the wandering/missing resident policy and held a quality assurance meeting.
• Staff checked all exit doors out of the facility and all wander guards currently being utilized in the building, placing any not working on 1:1 supervision.
• A complete headcount was performed, and the door codes were changed.
• LPN #1 was notified that Resident #1 could not be accounted for, and the Director of Nursing, Executive Director, Social Services Director, Medical Director, and Regional Director of Clinical Services were notified.
• Resident was located and safely returned to the facility.
• Once Resident was back inside the center, a head-to-toe body audit was completed with no injuries noted.
• The Assistant Maintenance Director performed checks on all exterior doors and windows, along with the wander guard system.
• Resident was immediately placed on 1:1 supervision and a 24-hour door monitor was put in place at the front.
• RN #2/Unit Manager began educating staff on elopement wandering risk policy, missing resident policy, following care plans, abuse and neglect, and resident's rights.
• The Director of Social Services reassessed Resident #1's Brief Interview for Mental Status.
• Wandering risk evaluation was completed on all residents.
• Elopement binders were updated and located at both nurses' stations and up front.
• An Ad hoc QAPI was held to discuss the incident and a plan of correction.
• In-servicing began on Wandering/Missing Resident, Prevention of Abuse and Neglect, and door alarms policies.
• The system will be checked daily by maintenance staff and the devices will be checked for placement each shift and checked for functionality daily by nursing staff.
• The daily checks of the door systems and placement of the patient devices, as well as the q shift checks of functionality of the patient devices, will be monitored by DON for completion.
• Monitoring has been put in place and the findings will be evaluated by the Quality Assurance and Improvement Committee.
• All corrective actions were completed and the Immediate Jeopardy was removed.

Penalty

Inspection fine: $10,361

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and assessment of a wandering alarm device, which resulted in a resident, identified as an elopement and wandering risk, exiting the facility unnoticed and unsupervised. The resident was wearing a wander alarm device that was found to be inoperable. This incident occurred when the resident exited the facility and walked approximately 0.7 miles, crossing a four-lane highway, before being located by facility staff and returned to the facility. The facility's policy on elopement and wandering risk required the placement and functionality of wander monitoring system devices to be checked every shift and daily, respectively. However, the staff did not adhere to this policy, as evidenced by the failure to test the resident's wander guard transmitter on the day of the incident. The maintenance department confirmed that the wander guard system was not functioning correctly, as the transmitters worn by residents at risk for elopement were not preventing the door from opening or sounding an alarm when a transmitter was within eight feet of the front door. The resident involved in the incident had a history of cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 99, which required a staff assessment for mental status. The resident had long and short-term memory problems and severely impaired cognitive skills for daily decision-making. Despite these known risks, the facility failed to ensure the proper functioning of the wander guard system, leading to the resident's unsupervised exit from the facility.

Removal Plan

• Resident #1 was assessed upon return to the facility and had no injuries, the wander guard device was found to be inoperable, and Resident was placed on one-on-one supervision.
• The facility reviewed the wandering/missing resident policy, educated staff on the wandering/missing resident policy and held a quality assurance meeting.
• Staff checked all exit doors out of the facility and all wander guards currently being utilized in the building, placing any not working on 1:1 supervision.
• A complete headcount was performed, and the door codes were changed.
• LPN #1 was notified that Resident #1 could not be accounted for, and the appropriate personnel were notified.
• CNA #1 showed a video of a man she saw walking next to Hwy 90, leading to the retrieval of Resident #1.
• Resident #1 was returned to the facility, and a head-to-toe body audit was completed with no injuries noted.
• The Assistant Maintenance Director performed checks on all exterior doors and windows, along with the wander guard system.
• The resident was placed on 1:1 supervision, and a 24-hour door monitor was put in place at the front.
• The door monitor continued until the wander guard system was verified to function properly.
• The door keypad codes were changed.
• RN #2/Unit Manager began educating staff on elopement wandering risk policy, missing resident policy, following care plans, abuse and neglect, and resident's rights.
• The Director of Social Services reassessed Resident #1's Brief Interview for Mental Status (BIMS).
• Wandering risk evaluation completed on all residents with no newly identified wandering risk.
• Elopement binders were updated and located at both nurses' stations and up front.
• An Ad hoc QAPI meeting was held to discuss the incident and a plan of correction.
• Interviews were conducted to learn of Resident #1's path, and it was discovered that Resident #1 most likely exited the front door when a visitor entered the facility.
• The incident was taken to a quality assurance performance improvement (QAPI) meeting, and no further action was needed.
• In-servicing began on Wandering/Missing Resident, Prevention of Abuse and Neglect, and door alarms policies.
• No staff was allowed to work before receiving education.
• The system will be checked daily by maintenance staff, and the devices will be checked for placement each shift and checked for functionality daily by nursing staff.
• Monitoring has been put in place and findings will be evaluated by the Quality Assurance and Improvement Committee.
• All corrective actions were completed and the Immediate Jeopardy was removed.

Penalty

Inspection fine: $12,048

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely incontinence care for six residents, leading to skin excoriations and other issues. Resident #57 was observed in a saturated and soiled brief, resulting in redness and excoriations on the perineal area and lower buttocks. Despite being cognitively intact and requiring substantial assistance, the resident was left in this condition for extended periods, as staff preferred to use two briefs to avoid frequent changes. The Medical Director and Director of Nursing were unaware of the severity of the excoriations until later observations and interviews confirmed the issue. Resident #55 was found wearing two incontinence briefs, which is against facility policy unless specifically care planned. The resident reported that CNAs sometimes applied multiple briefs to avoid changing him during the night. This practice was confirmed by an LPN and a CNA, who admitted to not checking on the resident as required. The resident had a current diagnosis of a urinary tract infection and required total dependence for toileting hygiene. Other residents, including Resident #1, Resident #8, Resident #14, and Resident #38, also experienced delays in incontinence care. Resident #1's call light was ignored, and he was not changed despite multiple requests. Resident #8 and Resident #14 were found in double briefs or soiled conditions, with staff failing to perform regular checks. Resident #38 was left in a soiled brief for over an hour, with staff citing meal tray distribution as a reason for the delay. These incidents highlight a systemic issue with timely incontinence care and adherence to facility policies.

Penalty

Inspection fine: $12,048

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS) for Quarter 1 of Fiscal Year 2023. The facility's policy on staffing requirements, effective since 2014, was not adhered to, resulting in the Metric of Excessively Low Weekend Staffing being triggered. The Payroll Based Journal (PBJ) data entry report for October, November, and December 2023 revealed that adjustments for salaried employees, specifically the Minimum Data Set (MDS) Staff RN, did not occur on weekends, leading to inaccurate reporting of weekend staffing levels. Interviews with the Human Resource Coordinator, an LPN, and the Administrator confirmed that the corporate office was responsible for submitting PBJ staffing data for all facilities in the corporation. The Human Resource Coordinator and the Administrator were unaware of the inaccuracies until the audit spreadsheet was reviewed. The LPN, responsible for making staffing schedules, confirmed that salaried staff had helped cover the schedule during the months in question. The Administrator acknowledged the importance of accurate PBJ reporting to CMS and recognized that it was ultimately the facility's responsibility to ensure the accuracy of the submitted data.

Penalty

Inspection fine: $12,048

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a pressure ulcer intervention, specifically a low air loss mattress, was continued after a room change for a resident. The resident, who had a Braden Scale score indicating a risk for pressure ulcers, had a physician's order for a low air loss mattress. However, when the resident was moved from the skilled unit to the long-term care unit, the mattress was not transferred to the new bed. This oversight was confirmed by the resident's family member, the Medical Doctor, and the Director of Nursing during interviews. The resident was admitted to the facility with a diagnosis of cervical spinal cord injury and was cognitively intact as indicated by a BIMS score of 15. The failure to transfer the low air loss mattress was acknowledged by the Medical Doctor during a care plan meeting, where he apologized to the resident's family member. The resident was later sent to the hospital due to abnormal laboratory findings and subsequently admitted to another facility after the hospital stay.

Penalty

Inspection fine: $12,048

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident's right to a dignified dining experience when staff did not provide incontinence care for a resident, resulting in odors in the resident's room and causing the meal to be unappetizing. On the specified date, a CNA entered the resident's room, acknowledged the resident's request for assistance, but did not provide the necessary care, stating she was passing out meal trays. However, no meal trays were being served at that time. The resident had to eat lunch while wearing a soiled brief, which made her uncomfortable due to the odor in the room. Further investigation revealed that the resident had been sitting in a soiled brief for over an hour and had to eat lunch in that condition. The resident reported this to two other CNAs who were unaware of her need for assistance before lunch. The resident's brief was heavily soiled, and the incontinence pad had a dark brown ring. The CNA who initially responded admitted she forgot to inform anyone about the resident's request. Interviews with the DON and the Administrator confirmed that it was unacceptable for a resident to remain in a soiled brief and that staff are expected to provide timely assistance and care.

Penalty

Inspection fine: $12,048

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safety of a resident with a known substance use disorder (SUD) by not assessing the risk of substance use and not developing appropriate interventions. Resident #57, who is cognitively intact and uses an electric wheelchair, frequently left the facility to visit a friend and consumed alcohol during these visits. Despite the resident's history of alcohol abuse and the fact that he returned to the facility impaired, no care plan or interventions were developed to address his SUD. Interviews with the resident, his family member, and facility staff, including the Director of Nursing (DON) and the Medical Director (MD), confirmed the lack of assessment and intervention for the resident's alcohol abuse problem. The resident's family member and the MD both indicated that the resident needed help with his alcohol abuse, but the facility had not recommended any programs or behavioral health services related to SUD. The resident was admitted to the facility with diagnoses including quadriplegia and an unspecified injury at the C1 level of the cervical spinal cord. His Annual Minimum Data Set (MDS) indicated that he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Despite this, the facility did not take appropriate measures to address his substance use disorder, leading to a deficiency in ensuring the resident's safety and well-being. The DON confirmed that the resident brought alcohol and tobacco products back into the facility and distributed tobacco to other residents, further highlighting the lack of appropriate interventions and supervision.

Penalty

Inspection fine: $12,048

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain its program during transitions in leadership and did not maintain implemented procedures or monitor interventions put in place in April 2022. This failure was evident in two recited deficiencies related to residents' rights and wound care. Specifically, the facility did not ensure a dignified dining experience for a resident by failing to provide incontinence care, resulting in odors that made the meal unappetizing. Additionally, the facility failed to continue a Pressure Ulcer (PU) intervention involving an air mattress after a room change for another resident. A review of the facility's policy and previous survey findings revealed that these issues were previously cited in April 2022. The deficiencies included not covering a resident during incontinence/catheter care and failing to provide wound care within professional standards. The current Administrator, who was not employed at the time of the previous survey, confirmed awareness of these citations. The continued failure during two surveys indicates a pattern of the facility's inability to sustain an effective QAPI Committee.

Penalty

Inspection fine: $12,048

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent the possible spread of infection as evidenced by improper medication handling and incontinence care practices. During a medication administration observation, a registered nurse placed a resident's pill into her ungloved hand before transferring it to a medication cup, which was confirmed by the nurse as a break in infection control. The facility's policy explicitly states that medications should not be touched with bare hands, and this was acknowledged by both the nurse involved and the Infection Preventionist during interviews. In another instance, certified nursing assistants were observed discarding soiled linens and briefs directly onto the floor during incontinence care for two residents. The facility's policy requires soiled items to be placed in a bag immediately to maintain proper infection control. Both the CNAs involved and a licensed practical nurse confirmed that the practice of placing soiled items on the floor was against the facility's infection control procedures. The Director of Nursing was informed of the incident and confirmed that the CNA had been trained and had competency skills check-off related to incontinence care and infection control.

Penalty

Inspection fine: $12,048

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement care plan interventions for three residents, leading to deficiencies in their care. Resident #55, who was admitted with diagnoses including Hemiplegia and Hemiparesis following a cerebrovascular disease, had a UTI but did not have a care plan developed for this condition despite being on antibiotics. Both the Director of Nursing (DON) and an LPN confirmed the absence of a care plan for the UTI, acknowledging that care plans should be updated with new physician orders to ensure proper care. Similarly, Resident #57, who had a history of alcohol abuse and was diagnosed with Quadriplegia, did not have a care plan addressing his Substance Use Disorder (SUD). The resident's family member and an LPN confirmed the lack of interventions or programs to assist with the SUD, despite the resident's increased alcohol consumption and need for help with substance abuse. Both residents were cognitively intact, with BIMS scores of 15, indicating they were aware of their conditions and the lack of appropriate care plans. Additionally, the facility failed to implement a care plan intervention for Resident #261, who required a low air loss mattress due to a cervical spinal cord injury. The resident was moved from the skilled unit to the long-term care (LTC) unit, but the therapeutic mattress was not transferred to the new bed. This oversight was confirmed by the DON and a family member, who attended a care plan meeting where the Medical Doctor (MD) apologized for the error. The comprehensive care plan for Resident #261 included the need for a therapeutic mattress, but this intervention was not executed, compromising the resident's care.