Olive Branch Health And Rehabilitation Center

Based on observations, interview, and record review, the facility failed to ensure medications were stored securely for 10 of 15 residents observed. (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11)On 2/23/2026 at approximately 10:00 am, during a tour of the facility, medications were observed located on the bedside table in the rooms of Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11. No staff were present in the rooms at the times observed.On 2/23/2026 at approximately 10:00 am, upon entering the room of Resident #8, the resident was observed seated in the room. A medication cup containing oral medication was noted on the bedside table. During the observation, Resident #7 picked up the medication cup and began taking the medications independently. No licensed nurse or staff member was present in the room at this time. Record review revealed no physician order authorizing self-administration of medication and no documented assessment of the resident's ability to safely self-administer medications for Resident #7.On 2/24/2026 at approximately 7:30 am, during a tour of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain posting of the daily staffing requirements at the beginning of the shift in a prominent place visible to residents and visitors for 2 of 4 days observed. The findings include: Upon tour of the facility on 4/6/25 and 4/7/25, there was no daily posting of the staff names in a prominent place for visitors and residents. On 4/7/25 at approximately 9:15 AM, an interview was conducted with the Staffing Coordinator, who indicated that she prints the staffing data to post daily on the counter behind the receptionist desk in the front lobby. The Staffing Coordinator further indicated that she lays it face up on the counter. When asked if the placement of the staffing posting is visible to residents and visitors, the staffing coordinator confirmed that placement would not be visible. She also stated that they used to keep it in a stand but they had stopped doing that for an unknown reason, but going forward it will be placed in the stand at the desk and will also place them at the nursing stations. On 4/7/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and policy review, the facility failed to ensure safe injection practices of intravenous medications by swabbing the rubber septum of the vial prior to accessing the medication for 1 of 12 residents sampled for medication administration. (Resident #71) The findings include: During a medication administration observation on 04/06/2025 at 1:03 pm, Staff A, a Registered Nurse (RN), administered Ertapenem (an antibiotic), 1 gram in 100 milliliters of normal saline, to Resident #71. The Ertapenam was contained in a glass vial with a rubber septum covered by a plastic cap. Staff A performed hand hygiene and popped the plastic cap off the vial using her bare hand. She then attached the vial to the 100 milliliter bag of normal saline without swabbing the rubber septum of the vial first. Staff A then administered the medication to Resident #71. In an interview afterwards, she acknowledged did not swab the top of the medication vial with alcohol before mixing with the bag of normal saline. In an interview on 4/06/25 at 3:16 PM, the Director of Nursing said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident interviews, and staff interview, the facility failed to provide a dining room to dine in for 1 out of 4 days observed. The findings include: A tour of the facility's dining area was conducted on Sunday, 4/06/25 at approximately 10:40AM. During this tour, the dining area was observed clean with dim lighting, and the tables were not set up to accommodate residents for lunch. An interview was conducted on 4/6/25 at approximately 12:15 PM, with the Certified Dietary Manager (CDM) concerning the fact that no one was eating in the dining room on Sunday during lunch. She stated that they were waiting for the facility to increase staffing for the weekend and that a plan is in the works. On 04/08/25 at approximately 11:25 AM, an interview was performed with Resident # 227 who was sitting at a dining room table reviewing the lunch menu to place an order. The resident stated, I have more options available here in the dining room then I do in my room. On Tuesday 04/08/25 at approximately 11:45AM, the dining area with was being used by about 15 residents throughout…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview the facility failed to establish/maintain ongoing communication and collaboration with the dialysis facility, for 2 of 2 residents reviewed for dialysis services. (Residents #35 and #131). The findings include: Resident #35 A review of Resident #35 medical record was conducted which revealed an order for hemodialysis on Monday, Wednesday and Friday at 9:30 AM. Review of the admission Minimum Data Set, (MDS), dated [DATE] revealed Resident #35 received dialysis services. A review was conducted of Resident #35 paper chart, which failed to reveal dialysis communication forms, or dialysis treatment run sheets. An interview was conducted with Staff F, LPN, Supervisor on 8/23/22 at approximately 1:59 PM who stated the facility does not get the dialysis communication form back from the dialysis unit and stated she must call the dialysis facility to get the records faxed. Staff F, LPN stated the nurses should fill out the top of the dialysis communication form and send…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility failed to review the Preadmission Screening and Resident Review (PASARR) for accuracy and update the form for 1 of 1 resident sampled for PASARR. (Resident #50). The findings include: On 8/22/22 at approximately 3:30 PM, an observation was made of Resident #50. She was noted to have limited cognitive, hearing, and verbal communication capabilities. A review of the admission record for Resident #50 revealed that she was admitted to the facility on [DATE] and had been diagnosed with an intellectual disability, developmental disorder of speech and language, a disorder of psychological development, anxiety disorder, and a mood disorder. The preadmission history completed at the hospital revealed that the resident had been residing at a group home for individuals with intellectual disabilities. A review of the PASARR form dated 5/26/22 was conducted. The form had a check in the box that indicated no diagnosis or suspicion of Serious Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, policy review and interview, the facility failed to obtain and document weekly weights as ordered by the physician for 1 of 2 residents reviewed for nutrition. (Resident #44) The findings include: Review of Resident #44's medical record revealed a physician order dated 8/4/22. The order stated, monitor weekly weights on Tuesdays prior to dialysis; every night shift on Mondays for weight loss. Weigh prior to dialysis, with a start date of 8/8/22. Review of the documented weights in the electronic medical record, (EMR), under the weights/vitals section was conducted on 8/23/22 which revealed the last weight documented was on 8/3/22. The documented weight was 85 pounds. There were no further weights documented. A review of the MAR (Medication Administration Record) revealed a check mark and staff initials on the scheduled days for weight, but no weights were documented. On 8/23/22 at approximately 1:40 PM an interview was conducted with Staff B, LPN, (Licensed Practical Nurse), who stated she does not know much about the nursing unit and was not sure when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review and policy review, the facility failed to provide appropriate respiratory care by failing to change oxygen tubing at least weekly, failing to store respiratory equipment utilized for aerosol treatments in a clean container between uses, and failing to clean the filter on the oxygen concentrator for 1 of 2 sampled residents. (Resident #228) The findings include: On 8/22/22 at approximately 11:45 AM, Resident #228 was observed, she was receiving oxygen via nasal cannula at 3 liters per minute by way of an oxygen concentrator. The filter on the back of the concentrator was covered with a thick layer of a dusty substance. (Photographic evidence obtained). The nasal cannula did not have a date and there was no storage bag for the oxygen tubing at the bedside. Resident #228 also had a nebulizer machine at her bedside. The nebulizer tubing and the attached aerosol mouthpiece were stored in the top drawer of the bedside table uncovered. The nebulizer tubing was not dated, and no storage bag was available for the nebulizer mouthpiece or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and policy review, the facility failed to appropriately manage post-surgical pain for 1 of 1 resident sampled for pain management. (Resident #235) The findings include: On 8/24/22 at approximately 8:40 AM, an observation of Resident #235, during which he was grimacing in pain, restless, and tightly guarding his lower abdomen. He had difficulty moving up in the bed when Nurse H, Licensed Practical Nurse (LPN) tried to assist him up in the bed to take his medication. He complained of pain 10 on a 1-10 pain rating scale. Resident #235 said that the last dose of pain medication was given was about 1:00 AM, earlier that morning. He explained that he asked for pain mediation at about 4:00 AM and the nurse told him that he was out of the pain medication, and he has not had any medication since. At this time Nurse H, LPN explained that Resident #235 had run out of Oxycodone on night shift. The Controlled Medication Utilization Record showed that the last dose of Oxycodone 10 milligrams (MG) with Acetaminophen 325 MG had been signed out for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were acknowledged with action to be taken to address the recommendation for 1 of 5 residents reviewed for drug regimen. (Resident #35) The findings include: A review of Resident #35 record revealed a diagnosis of end stage renal disease with dependence on hemodialysis. A review of Resident #35 medication orders was conducted. The facility provided ordered medication Sevelamer and Cinacalcet, both are phosphate binders and Megestrol for appetite stimulation. A review of the consultant pharmacy recommendation dated 8/19/22 was conducted. The recommendation was related to Sevelamer and Cinacalcet, the recommendation was to monitor labs every six months. The recommendation was signed by the Advanced Practice Register Nurse, (APRN), however, the APRN did not acknowledge whether to accept or decline the recommendation. A review of the recommendation dated 7/28/22 was conducted. The recommendation was related to Megestrol with a notation the medication has minimal effect on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.