Leakesville Rehabilitation And Nursing Center, INC

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the call light system accommodated the needs of a resident with contracted hands for one (1) of four (4) survey days that affected Resident #5.Findings include:A review of the facility's policy, Call Lights: Accessibility and Timely Response, dated 10/21/24, revealed, .Policy Explanation and Compliance Guidelines.3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system.A record review of the admission Record revealed the facility admitted Resident #5 on 2/13/23 with current diagnoses including Hemiplegia and Hemiparesis and Contractures of Right and Left Arms and Legs.A record review of the Skilled Evaluation dated 8/29/25, revealed Resident #5 had Impairment on both sides regarding upper and lower extremity range of motion and indicated he had contractures.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of…

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 staff interview, record review, and facility policy review, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment following the placement of a percutaneous endoscopic gastrostomy (PEG) tube for one (1) of 17 sampled residents. (Resident #1). Findings include:A review of facility's policy, MDS (Minimum Data Set) 3.0 Completion, dated 9/24/24, revealed, .Residents are assessed .in order to identify care needs.Policy Explanation and Compliance Guidelines.2d. Significant Change in Status Assessments (SCSA) - a comprehensive assessment completed within 14 days of the identification of a status change that meets the requirements.i. A significant change is a major decline or improvement in a resident's status that : (1) will not normally resolve itself without intervention by staff or by implementing standard disease-are of the resident's health status.requires interdisciplinary review and/or revision of the care plan.A record review of the admission Record revealed the facility admitted Resident #1 on 4/14/25 with current diagnoses…

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 and staff interviews, record review, and facility policy review, the facility failed to complete a bedrail assessment and obtain resident consent to ensure safe and appropriate bedrail use for one (1) of three (3) sampled residents reviewed for accidents/bedrails. (Resident #34).Findings include:A review of the facility's policy, Proper Use of Bed Rails, dated 2/5/2025, revealed, .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bedrails. 'Bed Rails' are adjustable metal or rigid plastic bars that attach to the bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. Resident Assessment 1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: . k. Mobility (in and out of bed) . 4. The resident assessment…

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 interviews and facility policy review, the facility failed to ensure food items were dated, labeled, stored, and maintained in a sanitary manner in accordance with facility policy and manufacturer instructions for one (1) of four (4) days of survey. Findings include:A review of the facility's policy, Food Receiving and Storage, revised July 2014, revealed, .Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation.6. All foods stored in refrigerator freezer should be covered labeled and dated.9.Wrappers of frozen food must stay intact until thawing .On 9/22/2025 at 10:36 AM, during an observation of the kitchen and interview with the Dietary Manager (DM), there was (1) gallon of Italian dressing stored in the refrigerator opened and undated. In the produce cooler, three (3) overly ripe cucumbers, (1) overly ripe head of lettuce beginning to deteriorate, (1) cucumber cut in half and left exposed/unwrapped, and three (3) green bell peppers overly ripe and beginning to dry were…

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, and facility policy review, the facility failed to ensure infection prevention and control practices were maintained as evidenced by, not discarding isolation gowns that had fallen to the floor in the hallway, and placing the contaminated gowns back in to the clean supply bin designated for PPE use by staff for one (1) of two (2) PPE supply bins observed. Findings include:A review of the facility's policy, Infection Prevention and Control Program revised 2/16/2024, revealed, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Policy Explanation and Compliance Guidelines.11. Supplies Protocol.c. Prepackaged sterile items are considered sterile until opened or damaged.On 09/25/2025 at 10:54 AM, during an observation of the PPE box adjacent to the conference room on F hall, four (4) plastic-wrapped isolation…

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, record review, and facility policy review, the facility failed to ensure a resident's right to privacy as evidenced by a resident who was visible on a video that was posted to a staff member's personal social media account without her consent for one (1) of four (4) sampled residents. Resident #1. Findings include: Review of the facility's policy, Resident Photographs/Videos, revised 2/14/23, revealed, Policy: Taking photographs and/or videos of residents or their personal belongings is a violation of residents' rights to privacy and confidentiality. Policy Explanation and Compliance Guidelines: 1. All photographs or videos of residents will only be taken by an employee having written authorization from the Administrator as indicated below .3. No employees will post pictures, videos, comments, etc., on social media that pertains to anyone within this facility . A record review of the Activity Photograph/Outing Release, dated 5/3/22, revealed Resident #1 signed an Activity Photograph Release which indicated, .For the use of photos, names and/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, staff and resident interview, record review, and facility policy review, the facility failed to have sufficient staff to assemble meal trays timely to prevent meals from being served late and cold for three (3) of four (4) days of survey. Findings include: Review of the facility's policy, Dietary Services-Staffing, revised 7/21/23, revealed, .The facility employs sufficient staff with the appropriate competencies in skill sets to carry out the functions of the Food and Nutrition Services, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment .Policy Explanation and Compliance Guidelines for Staffing .6. The facility will provide sufficient support personnel to carry out the supportive functions of the Food and Nutrition Services. These functions include .a. Safe and timely meal preparations . During an observation of the kitchen on 5/6/24 at 10:00 AM, the Dietary Manager (DM) and a Dietary Aide were present in the kitchen.…

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, record review, and facility policy review, the facility failed to provide resident meals at an appetizing temperature for two (2) of two residents reviewed for food. Resident #32 and Resident #109. This had the potential to affect all residents who receive meals from the kitchen. Findings include: A record review of the facility's policy, Food and Nutrition Services, revised 10/2017, revealed . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs .Policy Interpretation and Implementation: . 7. Food and nutrition services staff will inspect food trays to ensure .the food .is served at a safe and appetizing temperature . Resident #32 On 05/06/24 at 11:35 AM, during an interview with Resident #32, he complained the food was served cold daily at all meals. On 5/07/24 at 12:15 PM, during an observation, the facility staff were in the dining room with the meal tray carts and were reviewing trays. One (1) cart had six (6) trays and one (1) cart and nine (9) trays. 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 interview and record review the facility failed to accurately code the Minimum Data Set (MDS) related to a resident who was discharged to home but was coded as discharging to another facility for one (1) of 17 sampled residents. Resident #58 Findings include: A record review of the Physician's Telephone Orders revealed Resident #58 had a Physician's Order, dated 2/7/24, for May discharge home with home health and medication. A record review of the Discharge MDS with an Assessment Reference Date (ARD) of 2/7/24 revealed Resident #58 had an unplanned discharge to an Intermediate Care Facility. A record review of the Face Sheet revealed the facility admitted Resident #58 on 2/6/24 and he was discharged on 2/7/24. He had diagnoses including Altered Mental Status. On 5/9/24 at 8:50 AM, in an interview with Registered Nurse (RN) #1/MDS nurse, she acknowledged Resident #58 was coded as being discharged to an intermediate care facility in error because he was discharged to home. On 5/9/24 at 9:00 AM, in an interview with the Director of Nursing (DON), she acknowledged the MDS was…

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 interviews, record review, and facility policy review, the facility failed to implement the use of a sign language interpreter during clinical appointments for a resident who was deaf, which increased the risk of not having the resident's needs met and experiencing a possible decline in the physical and psychosocial well-being and quality of life for one (1) of 17 sampled residents. Resident #40 Findings include: A record review of the facility's document A Matter of Rights A Guide to Your Rights and Responsibilities as a Resident with a copyright date of 2020, revealed . No Discrimination: You have the right to fair and equal treatment . we will not treat residents differently based on .their medical diagnosis .We will meet all applicable rules requiring that we make available free communication aids and services, for example, by providing translation services or other language assistance . On 05/07/24 at 10:30 AM, Resident #40 attended the resident council meeting and the facility's Speech Therapist (ST) assisted her with communication during the meeting. Resident #40…

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 resident and staff interviews, record review, and the facility policy review, the facility failed to secure a resident in the facility van during transport for one (1) of two (2) residents reviewed for accidents. (Resident #43) Findings Include: Review of the facility's policy, Incident and Accidents, dated 5/13/2023, revealed, .It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur . Review of the facility's Fall Prevention Policy, dated 2/20/23, revealed, .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . Review of the Resident Incident Report for Resident #43, dated 10/4/23, revealed the facility investigated the incident and the Narrative of incident and description of injuries indicated the transporter stated that resident was strap in place in wheelchair and upon taking off in the van the resident chair flipped over backwards and resident stated he hit his head no injuries noted except…

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 interviews, record review, and facility policy review the facility failed to ensure residents quality of life was maintained as evidenced by the facility's failure to provide a clean and comfortable homelike environment, including clean, blood free linens for one (1) of 17 sampled residents. Resident # 32 Findings include: A record review of the facility's policy Safe and Homelike Environment, revised 2/12/2023 revealed . In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment .Policy Explanation and Compliance Guidelines .4. The facility will provide and maintain bed and bath linens that are clean and in good condition . On 5/6/24 at 11:30 AM, in an interview, Resident #32 complained he had gotten blood on his bed sheets and gown when he had a procedure for an intravenous (IV) line. He said he had to sleep on sheets and in a gown that had blood on them. On 5/6/24 at 12:40 PM, during an interview with Licensed Practical Nurse (LPN)#1, she explained she did not remember Resident #32's sheets and gown having blood…

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 staff interview, record review, and facility policy review, the facility failed to revise the Comprehensive Care Plan for one (1) of 14 sampled residents. Resident #43 Findings Include: A review of the facility's policy, Care Plans-Comprehensive, revised May 2014, revealed, .Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team maintains a comprehensive care plan for each resident .8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . A record review of the Face Sheet revealed the facility admitted Resident #43 on 1/18/22 with diagnoses including Generalized Anxiety Disorder and Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date (ARD) of 10/11/2022 revealed Resident #43 had an active diagnosis of Diabetes Mellitus. A record review of the Physician's Telephone Orders, dated 10/25/22, for Resident #43, revealed, .Jardiance 10 mg (milligrams) 1 tab(tablet) po (by mouth) q (every)…

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.