Senatobia Healthcare & Rehab

Penalty

No penalty information released

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

Medication administration was not completed in accordance with physician orders and accepted standards of practice for four residents observed during a medication pass, resulting in a 100% medication error rate for the observed medications. The facility policy stated that the facility must be free of medication error rates of 5% or greater. During observation, the assigned LPN stated she was responsible for 27 residents, had multiple duties beyond medication administration, and was still catching up on morning medications while working the pass. Resident #1 had multiple medications ordered for 9:00 AM, including medications for heart failure, cardiac arrhythmia, and diabetes, but the medications were documented as administered at 11:04 AM. Resident #3 had 8:00 AM and 9:00 AM medications, including respiratory, cardiac, ophthalmic, and bowel medications, and they were documented as administered at 12:52 PM. Resident #2 had 9:00 AM medications, including antiepileptic, anticoagulant, and other routine medications, and they were administered at 1:08 PM. Resident #4 had 9:00 AM medications, including aspirin, carvedilol, insulin glargine, lisinopril, and antiepileptic medications, and they were documented as completed at 11:28 AM. The RN supervisor stated nurses were expected to administer medications within a two-hour window and that if medications could not be given within that timeframe, they should not be given without further provider instruction. The DON reviewed the records for the four residents and verified that 55 of 55 ordered medications were administered late, resulting in a 100% error rate.

Penalty

No penalty information released

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 administer physician-ordered medications within the ordered time frame for three residents during medication administration observations and record review. Facility policy stated that residents should receive care and services safely in an environment free of significant medication errors. Resident #1, who had diagnoses including heart failure and unspecified cardiac arrhythmia and a BIMS score of 15, reported that her medications were late most of the time and said she wanted to take them earlier. Her Digoxin 125 mcg order was scheduled for 9:00 AM, but the Administration History Report showed it was given at 11:04 AM by LPN #1. Resident #2, who had diagnoses including epilepsy and long-term use of anticoagulants, was observed receiving scheduled 9:00 AM medications at 1:08 PM, four hours later than ordered. Those medications included Lamotrigine 100 mg, Lacosamide 200 mg, and Levetiracetam 750 mg. Resident #4, who had diagnoses including type II diabetes mellitus and unspecified epilepsy, had 9:00 AM medications documented as completed at 11:28 AM, including Divalproex Sodium Delayed Release 500 mg, Insulin Glargine 40 units, and Oxcarbazepine 150 mg. The DON reviewed the records and verified the medications were administered late and stated this was unacceptable practice.

Penalty

No penalty information released

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 protect a resident's right to be free from exploitation and misappropriation of personal funds. After being hospitalized and discharged to a specialty hospital, a resident's belongings were boxed and stored by a former Assistant Housekeeping Supervisor. Upon the resident's return, he reported missing items, including a cell phone, wallet with debit card, and clothing. The facility determined the phone had accompanied the resident to the hospital and replaced the missing clothing, but the resident later discovered that his debit card had been used without his consent. Interviews and record reviews confirmed that the former Assistant Housekeeping Supervisor, who had access to the resident's belongings, used the resident's debit card to make multiple unauthorized withdrawals totaling over $8,200. Surveillance footage from the bank showed the same individual making thirteen separate ATM transactions, and both the Administrator and DON identified the person as the former employee. The bank and law enforcement substantiated the exploitation, and the matter was referred as an elder abuse case. The resident, who was cognitively intact according to his MDS assessment, expressed feelings of betrayal and anger upon learning of the theft. Staff interviews confirmed that the act violated residents' rights and that the employee responsible had previously attended in-service training on abuse and misappropriation. The resident's account was eventually refunded by the bank, but the misappropriation of funds occurred while the resident's property was under the facility's care.

Penalty

No penalty information released

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 protect residents from misappropriation of medications, resulting in two residents not receiving their prescribed controlled substances as documented. An agency LPN signed out an oxycodone tablet for a resident with a femur fracture on the controlled substance log, but there was no documentation on the Medication Administration Record (MAR) that the medication was administered. Video surveillance confirmed that the LPN did not access the narcotic lock box when preparing and delivering medications to the resident’s room at the time in question. In a separate incident, another resident with a diagnosis of osteomyelitis reported not receiving his pain medication during the evening shift. The controlled substance log showed that a hydrocodone tablet was signed out and documented as administered by the same agency LPN, but video evidence revealed that the LPN did not enter the resident’s room after an early evening visit. The resident, who was cognitively intact, confirmed he did not receive his night medications, including pain medication, and that the nurse never returned after the initial visit. The Director of Nursing (DON) audited narcotic records for all residents assigned to the agency LPN and confirmed discrepancies, including medications signed out without corresponding MAR documentation and lack of observed access to the narcotic box. Staff interviews corroborated that residents reported not receiving their medications, and the DON acknowledged the risks associated with diversion of narcotics and the importance of safeguarding residents’ medications.

Penalty

No penalty information released

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 residents were free from significant medication errors, as evidenced by six residents not receiving their scheduled medications on a specific evening shift. An agency LPN documented in the electronic medication administration record that all medications were given, but the next morning, multiple sealed medication packets were found unopened on the medication cart. The medications involved included treatments for conditions such as low blood pressure, Candida infection, epilepsy, hypertension, and muscle spasms. The residents affected had diagnoses including heart failure, symptomatic epilepsy, osteomyelitis, and hypertensive heart disease. Interviews with facility staff confirmed that the medications were not administered as documented. The DON reviewed the records and confirmed that the missed doses for the six residents constituted significant medication errors. One resident reported not receiving his night medications, including pain medication, and stated that the nurse did not return to his room despite his calls. The LPN involved later claimed to have experienced computer issues and signed off medications in the system after giving them, not realizing some remained on the cart. Other staff, including another LPN and the Registered Charge Nurse, corroborated that the unopened medication packets were found and that the affected residents were assessed for adverse consequences, with only one resident voicing a complaint. The facility's policy required that residents receive care and services safely and in an environment free of significant medication errors, which was not followed during this incident.

Penalty

No penalty information released

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 residents or their representatives were involved in the care planning process for two of 28 residents reviewed for care planning, Residents #21 and #87. The facility policy titled, Care Planning-Resident Participation, stated that the facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment. Resident #21 stated during interview that she had not attended a care plan meeting but would like to, and her record showed she was admitted with a diagnosis of malignant neoplasm of endometrium and had a BIMS score of 9, indicating mild cognitive impairment. Resident #87 stated during interview that she could not remember the last time she had a care plan meeting, but it had been a while, and she would like to attend her care plan meetings. Her record showed she was admitted with a diagnosis of chronic atrial fibrillation and had a BIMS score of 15, indicating she was cognitively intact. The SS stated she uses the MDS ARD to determine when care plan meetings should be held, verbally notifies residents and asks if they want to attend on the day of the care plan, but does not document attendance. She also stated she usually calls the resident representative on the ARD for the care plan meeting, but Resident #21, Resident #87, and their representatives had not been invited to the last care plan meeting because she was behind on them. The Administrator agreed it was his expectation that residents and their representatives would be invited to the care plan meeting.

Penalty

No penalty information released

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 complete and transmit Comprehensive MDS assessments within the timeframes required by the RAI User’s Manual for 3 of 33 assessments reviewed. Record review showed that Resident #39’s annual MDS with an ARD of 7/01/25 was not completed and/or transmitted within the required timeframe, and Section Z item Z0500B was not dated and signed as complete by the RN Assessment Coordinator. Resident #39’s admission record showed the resident was admitted with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Resident #69’s Admission/Medicare 5 Day MDS with an ARD of 7/14/25 was also not completed and/or transmitted within the required timeframe. Resident #69’s admission record showed the resident was admitted with a diagnosis of periprosthetic fracture around another internal prosthetic joint, subsequent encounter. Resident #95’s annual MDS with an ARD of 7/2/25 was not completed and/or transmitted within the required timeframe, and Section Z0500B was left unsigned. During interview, the MDS Coordinator stated she was aware the MDS assessments for Resident #95 had not been completed or transmitted timely and said she had fallen behind due to the number of admissions, readmissions, and discharges. The Administrator stated he had been informed of late MDS assessments and agreed it was his expectation that MDS assessments be completed timely, but attributed the delays to an increase in admissions. Resident #95’s admission record showed a diagnosis including heart failure.

Penalty

No penalty information released

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 complete and transmit Quarterly and Discharge MDS assessments within the required time frame for 10 of 33 assessments reviewed. The affected residents were #24, #35, #58, #63, #82, #90, #105, #107, #108, and #118. Facility policy titled MDS 3.0 Completion date implemented 2/01/2025 stated that Quarterly assessments are to be completed using an ARD no greater than 92 days from the most recent prior quarterly or comprehensive assessment, Discharge assessments are to be completed within 14 days of the discharge date/ARD, and all assessments are to be transmitted to iQIES within 14 days of completion. Record review showed that Resident #24 had a Quarterly MDS with an ARD of 7/1/25, Resident #35 had a Quarterly MDS with an ARD of 6/27/25, Resident #58 had a Quarterly MDS with an ARD of 6/30/25, Resident #82 had a Quarterly MDS with an ARD of 7/1/25, Resident #90 had a Quarterly MDS with an ARD of 6/20/25, Resident #105 had a Quarterly MDS with an ARD of 7/2/25, Resident #107 had a Quarterly MDS with an ARD of 6/19/25, Resident #108 had a Quarterly MDS with an ARD of 6/23/25, and Resident #118 had a Quarterly MDS with an ARD of 6/20/25 that were not completed and/or transmitted within the required timeframes. Resident #63 had a Discharge MDS with an ARD of 3/22/25 that was also not completed and/or transmitted timely. The residents’ admission records listed diagnoses including acute posthemorrhagic anemia, acute on chronic diastolic heart failure, aphasia following cerebral infarction, fluid overload, type 2 diabetes mellitus with diabetic chronic kidney disease, venous insufficiency, diabetes mellitus, dementia, heart failure unspecified, and metabolic encephalopathy. The MDS Coordinator stated the assessments had fallen behind due to the number of admissions, readmissions, and discharges, and the Administrator confirmed awareness that the MDS assessments were late.

Penalty

No penalty information released

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 an accurate MDS assessment was coded for one resident out of 33 MDS assessments reviewed. Resident #122’s progress note documented that the resident was discharging home, but the discharge MDS with an ARD of 7/18/25 coded the discharge status as short-term general hospital. During interview, the MDS nurse confirmed the discharge MDS was inaccurately coded, stated the resident was discharged home, and acknowledged she completed the assessment. The Administrator also verified that the expectation was for the MDS to be coded accurately. The resident had been admitted with a diagnosis of fracture of the right femur.

Penalty

No penalty information released

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 comprehensive care plans for two residents with personal hygiene needs, resulting in missed scheduled showers. One resident, who had a self-care performance deficit related to muscle weakness and required assistance with activities of daily living (ADLs), reported missing several scheduled showers and documented only receiving one shower per week during the month in question. Facility records confirmed that this resident did not receive showers on multiple scheduled days, despite care plan interventions indicating the need for assistance with hygiene and bathing. The resident was cognitively intact and able to recall and document missed showers. Another resident, with a history of cerebral infarction, hemiplegia, and limited mobility, also reported not receiving scheduled showers and could not recall receiving any showers during the previous week. Documentation showed that this resident received only a few showers during the month, with several scheduled showers missed. Both residents' care plans specified the need for assistance with personal care, but the plans were not followed. Facility staff interviews confirmed the missed showers and acknowledged the lack of a reliable system for tracking and ensuring completion of personal hygiene care.

Penalty

No penalty information released

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 necessary care and assistance with activities of daily living (ADLs), specifically personal hygiene, for two residents who required help with these tasks. Both residents were cognitively intact and able to report their experiences. One resident reported missing several scheduled showers, stating that she was supposed to receive showers three times a week but had only been receiving about one per week during the month in question. She kept a personal record and noted specific dates when showers were missed, and also reported that staff did not offer or mention showers on those days. The resident described feeling dirty and socially withdrawn as a result. Review of facility documentation, specifically the Continuous Pressure Ulcer Monitoring Sheets used to track showers and baths, confirmed that both residents missed multiple scheduled showers. The records showed gaps on days when showers were supposed to be provided, and there was no documentation of refusals or alternative care being offered. Both residents had medical conditions requiring assistance with personal care, including chronic obstructive pulmonary disease, muscle weakness, cerebral infarction, and hemiplegia. Interviews with staff, including LPNs, CNAs, and supervisors, revealed that the process for documenting showers involved CNAs filling out sheets and nurses signing off, but there were missing records for the affected residents. Staff acknowledged the documentation gaps and confirmed that the lack of records likely indicated the showers were not provided. Supervisory staff were unaware of the missed care until the issue was brought to their attention during the survey.

Penalty

Inspection fine: $8,021

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 effective comprehensive care plan interventions for a resident at risk for wandering and elopement. The resident, who had a history of cerebral vascular accident and was cognitively intact with a BIMS score of 14, was left unattended on the facility's front porch. Despite wearing a Wander Guard, the resident exited the premises unnoticed and was later found at a grocery store approximately 0.3 miles from the facility. Interviews with facility staff, including the Director of Nursing, a CNA, and an LPN, confirmed that the resident was often left unattended on the porch, despite being at risk for elopement. The care plan for the resident, which included the use of a Wander Guard and regular checks, was not followed, leading to the resident's unsupervised departure from the facility. The State Agency identified an Immediate Jeopardy situation due to the facility's failure to adhere to its policy on elopement and wandering residents. The deficiency was noted as a serious risk to the resident's safety, as well as to other residents at risk for wandering and elopement.

Removal Plan

• A passerby notified Certified Nursing Assistant #1 that she observed an individual walking up the hill that she suspected to be a resident of the center. CNA #1 immediately came into the facility and notified the receptionist. A search by staff was initiated.
• The Center's Infection Control Preventionist got in her car to go off premises to look for Resident #1. Resident #1 was observed by the Infection Control Preventionist approximately a quarter mile from the facility outside a local grocery store and successfully encouraged to get in the car.
• Resident #1 returned to the facility.
• The Licensed Practical Nurse completed a body audit on the resident with no injuries noted.
• Resident #1 was placed on hourly staff monitoring for 24 hours.
• Licensed Nurses ensured all residents were in-house via visual observation.
• Education was initiated by the Director of Nursing and a Registered Nurse Supervisor on the elopement prevention policy to include the provision that any resident at risk for elopement will receive ongoing staff supervision while outside the center for all staff. No staff will be allowed to work until in serviced.
• The State Survey Agency and Attorney General's office was notified by the interim Director of Nursing.
• Resident #1, who is alert and oriented, was provided education by the Director of Nursing to notify staff anytime she wished to go outside or leave the center.
• The Director of Nursing and a Registered Nurse Supervisor completed elopement risk assessments on all residents to determine their risk of leaving the center without adequate staff supervision.
• The Quality Assurance and Performance Improvement (QAPI) Committee attended by the Director of Nursing, the Medical Director via phone, Infection Control Preventionist, and the Nursing Home Administrator updated the facility's policy on Elopement Prevention to include any resident at risk for elopement would receive ongoing staff supervision while outside the center.
• A new Nursing Home Administrator started.
• A Resident Council meeting was held by the Activities Director to provide education to residents to notify their licensed nurse and to sign out prior to leaving the center.
• Care plans on all residents at risk for elopement were reviewed and updates initiated by the Administrator and Minimum Data set (MDS) Coordinator to ensure they reflect individualized interventions for those residents at risk for wandering and elopement.
• The Director of Nursing initiated education on importance of accuracy of care plan interventions related to wandering/elopement prevention to Minimum Data Set Nurses (MDS), Infection Control Preventionist, Registered Nurse Supervisors, and Medical Records Coordinator.
• A 100 percent (%) Care Plan audit was conducted by the Administrator and MDS Nurses with updates for current interventions made to care plans to ensure compliance for residents at risk for elopement.
• Resident #1's care plan was updated by the MDS Coordinator with current interventions for elopement prevention.
• An Ad Hoc Quality Assurance meeting was held to discuss the Immediate Jeopardy Removal Plan and corrective actions, interventions, and education to ensure compliance. As part of the Ad Hoc QAPI Meeting, in-service completion for both the all-staff education on the elopement prevention policy and the importance of accurate and effective care plan interventions related to wandering/elopement prevention education for the Interdisciplinary Team (IDT) was reviewed by the Administrator and QAPI Committee Members with further instruction that no staff will be allowed to work until in serviced. It was attended by the Medical Director, Director of Nursing, Infection Control Nurse, Administrator, and RN Supervisor.

Penalty

Inspection fine: $8,021

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 to prevent a resident, identified as an elopement and wandering risk, from leaving the premises unnoticed and unsupervised. The resident was left on the front patio and subsequently exited the facility without staff awareness. Video surveillance footage confirmed that the resident left the facility at 4:05 PM and was later found at a grocery store approximately 0.3 miles away at 4:25 PM. This incident placed the resident and potentially other residents at risk for serious harm or injury. Interviews with staff revealed that the resident frequently sat outside on the porch unattended, despite being at risk for elopement. The Director of Nursing confirmed that the resident should not have been left unattended, and staff should have been present. The Front Office Receptionist admitted to turning off the door alarm to allow the resident to sit on the porch without staff supervision, and no one was monitoring the resident during this time. The resident, who is cognitively intact, recounted that she left the facility to buy tobacco and walked through parking lots without going near the street. The facility's policy on elopement and wandering residents was not followed, as the resident was not provided with adequate supervision in accordance with her person-centered plan of care. The failure to adhere to this policy resulted in the resident's unsupervised departure from the facility.

Removal Plan

• A passerby notified Certified Nursing Assistant #1 that she observed an individual walking up the hill that she suspected to be a resident of the center. CNA #1 immediately came into the facility and notified the receptionist. A search by staff was initiated.
• The Center's Infection Control Preventionist got in her car to go off premises to look for Resident #1. Resident #1 was observed by the Infection Control Preventionist approximately a quarter mile from the facility outside a local grocery store and successfully encouraged to get in the car.
• Resident #1 returned to the facility.
• The Licensed Practical Nurse completed a body audit on the resident with no injuries noted.
• Resident #1 was placed on hourly staff monitoring for 24 hours.
• Licensed Nurses ensured all residents were in-house via visual observation.
• Education was initiated by the Director of Nursing and a Registered Nurse Supervisor on the elopement prevention policy to include the provision that any resident at risk for elopement will receive ongoing staff supervision while outside the center for all staff. No staff will be allowed to work until in serviced.
• The State Survey Agency and Attorney General's office was notified by the interim Director of Nursing.
• Resident #1, who is alert and oriented, was provided education by the Director of Nursing to notify staff anytime she wished to go outside or leave the center.
• The Director of Nursing and a Registered Nurse Supervisor completed elopement risk assessments on all residents to determine their risk of leaving the center without adequate staff supervision.
• The Quality Assurance and Performance Improvement (QAPI) Committee attended by the Director of Nursing, the Medical Director via phone, Infection Control Preventionist, and the Nursing Home Administrator updated the facility's policy on Elopement Prevention to include any resident at risk for elopement would receive ongoing staff supervision while outside the center.
• A new Nursing Home Administrator started.
• A Resident Council meeting was held by the Activities Director to provide education to residents to notify their licensed nurse and to sign out prior to leaving the center.
• Care plans on all residents at risk for elopement were reviewed and updates initiated by the Administrator and Minimum Data set (MDS) Coordinator to ensure they reflect individualized interventions for those residents at risk for wandering and elopement.
• The Director of Nursing initiated education on importance of accuracy of care plan interventions related to wandering/elopement prevention to Minimum Data Set Nurses (MDS), Infection Control Preventionist, Registered Nurse Supervisors, and Medical Records Coordinator.
• A 100 percent (%) Care Plan audit was conducted by the Administrator and MDS Nurses with updates for current interventions made to care plans to ensure compliance for residents at risk for elopement.
• Resident #1's care plan was updated by the MDS Coordinator with current interventions for elopement prevention.
• An Ad Hoc Quality Assurance meeting was held to discuss the Immediate Jeopardy Removal Plan and corrective actions, interventions, and education to ensure compliance. As part of the Ad Hoc QAPI Meeting, in-service completion for both the all-staff education on the elopement prevention policy and the importance of accurate and effective care plan interventions related to wandering/elopement prevention education for the Interdisciplinary Team (IDT) was reviewed by the Administrator and QAPI Committee Members with further instruction that no staff will be allowed to work until in serviced. It was attended by the Medical Director, Director of Nursing, Infection Control Nurse, Administrator, and RN Supervisor.