Choctaw Residential Center

F-F0500 . F. How important is it to you to do your favorite activities? Very important was marked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 255339 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255339 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Choctaw Residential Center 135 Residential Center Rd Choctaw, MS 39350

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm 47874

Residents Affected - Few Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure hand rolls were applied for a resident with finger contractures for one (1) of 25 sampled residents. Resident #74

Findings Include:

Review of the facility policy titled Prevention of Decline in Range of Motion unrevised, revealed under, Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable.

Record review of the Treatment Administration Record (TAR) revealed an order dated 7/08/24, Caregiver to don (put on) B (bilateral) hand rolls to B (bilateral) hands to decrease risk of skin breakdown and decrease risk of further contracture formation with skin checks/cleanse at the end of each shift to ensure no adverse effects x (times) 7 days a week every shift. The hand rolls were signed as applied/administered on each shift (day, evening, and night) for the dates of 3/3/25 and 3/4/25.

An observation on 3/03/25 at 12:00 PM revealed Resident #74 lying in bed. Contractures observed to both hands/fingers with no device in place for contracture management.

An observation of Resident #74 on 3/04/25 at 10:15 AM revealed he was lying in bed without hand rolls in place.

An observation and interview on 3/05/25 at 7:50 AM with Resident #74 revealed the resident was lying in bed with no hand rolls in place. The resident voiced that sometimes the staff applied a hand towel inside his hands but confirmed that he did not have any now.

An observation and interview with Registered Nurse (RN) #1 on 3/05/25 at 8:00 AM confirmed Resident #74 were supposed to have hand rolls that the nurses applied, but did not have the hand rolls in place. She revealed the resident could develop worsening contractures and skin breakdown by not wearing them as ordered.

Record review of the Therapist Progress & (and) Discharge Summary dated 1/04/24 revealed under, Discharge Plans & (and) Instructions: Patient discharged to nursing care for placement of B (bilateral) hands rolls to decrease risk of skin breakdown as well as decreased risk of further contracture formation.

An interview with the Occupational Therapist (OT) on 3/05/25 at 8:34 AM revealed she recommended Resident #74 to wear hand rolls due to his severe hand/finger contractures. She revealed the purpose of him wearing them was to prevent skin breakdown and further worsening of his contractures, and confirmed without staff applying them, his contractures could become worse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 255339 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255339 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Choctaw Residential Center 135 Residential Center Rd Choctaw, MS 39350

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 An interview with the Administrator (ADM) on 3/5/25 at 2:00 PM confirmed that the staff should be applying Resident #74's hand rolls or have documentation to reflect why it was not. Level of Harm - Minimal harm or potential for actual harm Record review of the Admission Record revealed the facility admitted Resident #74 on 2/02/22 with medical diagnoses that included Cerebral Infarction and Hemiplegia Unspecified Affecting the Left Nondominant Residents Affected - Few Side.

Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated that Resident #74 was cognitively intact. Also revealed under section GG, functional limitation in range of motion (shoulder, elbow, wrist, hand), impairment on both sides was marked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 255339 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255339 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Choctaw Residential Center 135 Residential Center Rd Choctaw, MS 39350

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47157 potential for actual harm Based on observations, resident and staff interviews, record review and facility policy review, the facility Residents Affected - Few failed to maintain a medication error rate less than 5% as evidence by the administration of discontinued and incorrectly scheduled medications and failure to administer prescribed medications. This deficient practice was identified in four (4) of 37 medication administration observation opportunities. The medication error rate was 10.81%. This affected Resident #39 and Resident #90.

CROSS REFERENCE

F-F658

Findings include:

A review of the policy titled Medication Administration revealed the following, Policy: Medications are administered by licensed nurses who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines: Section 10 states that staff must ensure the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, and f. Right documentation .

Resident #39

An observation of Licensed Practical Nurse (LPN) #1 on 3/05/25 at 8:15 AM, administering medications revealed that LPN #1 administered Glipizide 10 mg (milligrams) (one tablet orally) and Albuterol Sulfate HFA Inhaler 108 (90 Base) (2 puffs) to Resident #39. LPN #1 did not verify the six rights of medication administration by comparing the medication label with the electronic/paper medication administration record

before administration.

Record review of the Medication Administration Record for 3/05/25 for Resident #39 revealed Glipizide 10 mg was discontinued on 3/03/25. Albuterol Sulfate inhaler was scheduled every six hours at 6:00 AM, 1200 PM, 6:00 PM (1800), and 12:00 AM (0000). The medication was last signed off at 6:00 AM. Mometasone Furoate inhaler signed off as administered at 8:00 AM on 3/05/25.

On 3/5/25 at 1:10 PM, during an interview LPN #1 confirmed that she made medication errors when administering Resident #39's medications. She admitted that she administered Glipizide 10 mg, which had been discontinued on 3/3/25 and also Albuterol Sulfate HFA inhaler at an incorrect time, as it had already been given at 6:00 AM. She then confirmed that she also documented administration of Mometasone Furoate inhaler at 8:00 AM, despite not administering it. She acknowledged that failure to verify the six rights of medication administration could lead to adverse resident outcomes.

Resident Admission Record: Resident #39 was admitted on [DATE REDACTED], with diagnoses including Type 2 Diabetes Mellitus and Chronic Systolic Congestive Heart Failure.

Resident #90

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 255339 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255339 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Choctaw Residential Center 135 Residential Center Rd Choctaw, MS 39350

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 An observation of LPN #4 administering medications on 3/05/25 at 8:46 AM, revealed that LPN #4 administered Aspirin Enteric Coated (EC) 81 mg to Resident #90. LPN #4 did not verify the six rights of Level of Harm - Minimal harm or medication administration by checking the medication label against the medication record. potential for actual harm

Record review of the Medication Administration Record for 3/05/25 for Resident #90 revealed Aspirin 81 mg Residents Affected - Few chewable tablet signed off as administered.

On 3/5/25 at 1:20 PM, during an interview LPN #4 confirmed after reviewing the medication record that she gave the incorrect form of aspirin when she administered Aspirin EC 81 mg, but later realized it was not the correct medication. She also confirmed she did not thoroughly check the six rights of medication administration and stated that if she had done so, she likely would not have made the error.

Record review of Resident #90's Admission Record revealed the facility admitted the resident on 1/04/25, with diagnoses that included End-Stage Renal Disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 255339 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255339 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Choctaw Residential Center 135 Residential Center Rd Choctaw, MS 39350

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 47874 Residents Affected - Few Based on observation, staff interview, and facility policy review, the facility failed to ensure a medication cart was locked and secured for one (1) of four (4) survey days.

Findings Include:

Review of the facility policy titled Medication Storage unrevised, revealed, Policy Explanation and Compliance Guidelines . c. During a medication pass, medications must be under the direct observation of

the person administering medications or locked in the medication storage area/cart.

An observation on 3/03/25 at 12:45 PM revealed the medication cart located on C hall was unlocked and unattended without a nurse in view.

An observation and interview with Licensed Practical Nurse (LPN) #1 on 3/03/25 at 12:49 PM confirmed she walked away from the medication cart and left it unlocked. She explained that she got called away and forgot to lock it. LPN #1 revealed leaving the medication cart unlocked gave the residents access to the cart and stated, Any of the residents can get in it and take something.

An interview with the Administrator (ADM) on 3/04/25 at 10:11 AM confirmed the nurses should never leave

the medication cart unlocked when out of view. She revealed that any resident could walk by and take some medication and have an allergic reaction.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 255339

F-F759

Findings include:

A review of the policy titled Medication Administration revealed the following: Policy: Medications are administered by licensed nurses who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.Policy Explanation and Compliance Guidelines: Section 10 states that staff must ensure the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, and f. Right documentation.

Resident #39

On 3/05/25 at 8:15 AM, an observation of Licensed Practical Nurse (LPN) #1 administering medications revealed that LPN #1 administered Glipizide 10 mg (milligrams) one tablet orally and Albuterol Sulfate HFA Inhaler 108 (90 Base) (2 puffs) to Resident #39. LPN #1 was not observed verifying the six rights of medication administration by checking the medication label against the medication record.

Record review of the Medication Administration Record for 3/05/25 for Resident #39 revealed Glipizide 10 mg (milligrams) was discontinued on 3/03/25.Albuterol Sulfate inhaler was scheduled every six hours at 6:00 AM, 1200 PM, 6:00 PM (1800), and 12:00 AM (0000). The medication was last signed off at 6:00 AM. Mometasone Furoate inhaler signed off as administered at 8:00 AM on 3/05/25.

During an interview on 3/5/25 at 1:10 PM, LPN #1 confirmed that she administered Glipizide 10 mg, which had been discontinued on 3/3/25. She also confirmed that she administered Albuterol Sulfate HFA inhaler at

an incorrect time, as it had already been given at 6:00 AM. LPN #1 lastly confirmed that she documented administration of Mometasone Furoate inhaler at 8:00 AM, despite not administering it. She acknowledged that failure to verify the six rights of medication administration could lead to adverse resident outcomes.

Record revew of the Admission Record of Resident #39 revealed was admitted on [DATE REDACTED], with diagnoses including Type 2 Diabetes Mellitus and Chronic Systolic Congestive Heart Failure.

Resident #90

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 20 255339 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255339 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Choctaw Residential Center 135 Residential Center Rd Choctaw, MS 39350

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 On 3/05/25 at 8:46 AM, an observation of LPN #4 administering medications revealed that LPN #4 administered Aspirin Enteric Coated (EC) 81 mg to Resident #90. LPN #4 did not verify the six rights of Level of Harm - Minimal harm or medication administration by checking the medication label against the medication record. potential for actual harm

Record review of the Medication Administration Record for 3/05/25 for Resident #90 revealed Aspirin 81 mg Residents Affected - Few chewable tablet signed off as administered.

During an interview on 3/5/25 at 1:20 PM, LPN #4 confirmed that she administered Aspirin EC 81 mg, but later realized it was not the correct medication. She confirmed after reviewing the medication record that she gave the incorrect form of aspirin. She also confirmed she did not thoroughly check the six rights of medication administration and stated that if she had done so, she likely would not have made the error.

Record review of the Admission Record revealed Resident #90 was admitted on [DATE REDACTED], with a diagnosis of End-Stage Renal Disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 20 255339 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255339 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Choctaw Residential Center 135 Residential Center Rd Choctaw, MS 39350

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 47874 potential for actual harm Based on observation, resident and staff interview, record review, and facility policy review, the facility failed Residents Affected - Few to ensure a resident dependent on staff for Activities of Daily Living (ADLs) received oral care and nail care for one (1) of 25 sampled residents. Resident #74

Findings Include:

Review of the facility policy titled Activities of Daily Living Policy with a revision date of 7/2014, revealed under, Policy Statement: Based on previous evaluations and current date, the nursing staff, in conjunction with Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify the level of care a resident requires for ADLs.

An observation of Resident #74, on 3/03/25 at 12:00 PM, revealed he was lying in bed with fingernails that were approximately 1 inch (in.) in length on the left hand with a brown substance on each nail and one nail that was broken off and hanging inside his palm. The residents' upper and lower teeth and lower gum line were covered in a thick white substance.

An observation with interview on 3/05/25 at 7:50 AM with Resident #74 revealed no change in the resident's appearance and he stated that he had asked the staff in the past to brush his teeth.

An observation and interview with Registered Nurse (RN) #1 on 3/05/25 at 8:00 AM confirmed Resident #74 had long nails on the left fingers that could cause skin breakdown due to his contracted fingers, which were turned inward toward the palm. She revealed the nurses, or the aides, could trim his nails. RN #1 described

the residents' teeth as, They need brushing. She confirmed that staff failing to do this could cause gingivitis and tooth decay. She revealed the aides were responsible for brushing his teeth daily.

An interview with the Administrator (ADM) on 3/05/25 at 2:00 PM revealed her expectations were for staff to perform the care tasks listed and document accordingly.

Record review of the March 2025 Documentation Survey Report for Resident #74 revealed the resident requires total dependence for personal hygiene with the assist of 1- two (2) staff.

Record review of the Admission Record revealed the facility admitted Resident #74 on 2/02/22 with medical diagnoses that included Cerebral Infarction and Hemiplegia Unspecified Affecting the Left Nondominant Side.

Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated that Resident #74 was cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 255339 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255339 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Choctaw Residential Center 135 Residential Center Rd Choctaw, MS 39350

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41878 potential for actual harm Based on resident and staff interviews, record review, and facility policy review, the facility failed to provide Residents Affected - Few activities that met the interest of the residents for three (3) of 25 sampled residents. Resident #6, #9, and #41

Findings Include:

Review of the facility policy titled Activities revealed under, Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being.

Resident #6

During an interview on 3/4/25 at 9:00 AM, Resident #6 stated the facility does not offer activities on the weekends and she would like to have activities on these days as well as during the week. She revealed she had been sick and had preferred to do activities in her room, but lately she felt better and wanted to participate in group activities.

An interview with the Activity Director (AD) on 3/5/25 at 8:00 AM, revealed she worked Monday through Friday and on the weekends the charge nurse would assist the residents with independent activities. She stated she left puzzles and coloring sheets for the residents that wanted to do those activities. She stated that church groups would occasionally have services in the facility on the weekend, but otherwise, she confirmed there were no organized group activities planned for the residents on the weekend.

An interview with the Administrator (ADM) on 3/6/25 at 8:45 AM, revealed the facility did not have a weekend activity staff member, but she was attempting to hire one. She stated the Activity Director would leave puzzles and coloring sheets for the residents. She confirmed the facility failed to provide structured and scheduled activities on the weekends for the residents that preferred to participate on those days.

Review of the February and March 2025 activity schedules confirmed on Saturdays and Sundays Independent activities of choice was listed.

Record review of the February 2025 Activity Attendance Record for Resident #6 revealed there was no activity documentation for the weekend days.

Record review of Resident #6's Admission Record revealed the facility admitted her on 12/16/2020. Her diagnoses included Hemiplegia and Hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus, and Dementia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 255339 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255339 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Choctaw Residential Center 135 Residential Center Rd Choctaw, MS 39350

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Record review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/24 Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated this Level of Harm - Minimal harm or resident was cognitively intact. Review of section F revealed for the question how important is it to you to do potential for actual harm your favorite activities and the resident's response was very important.

Residents Affected - Few Resident #9

During an interview on 3/04/25 at 8:46 AM, Resident #9 stated she participated in the bingo and singing activities during the week, but there were not any activities on the weekends. She stated she would like for

the facility to offer activities on the weekend for her and other residents to participate in.

Record review of the February 2025 Activity Attendance Record for Resident #9 revealed there was no activity documentation for the weekend days of the month.

Record review of Resident #9's Admission Record revealed the facility admitted the resident on 7/6/2018 originally with the most recent admitted [DATE REDACTED]. Diagnoses included Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction.

Record review of Resident #9's MDS with an ARD of 10/24/24 Section C revealed a BIMS score of 15 which indicated the resident was cognitively intact. Review of Section F revealed for the question how important is

it to you to do your favorite activities and the resident's response was very important. For the question how important is it to you to do things with groups of people the resident's response was very important.

47874

Resident #41

An interview with Resident #41 on 3/05/25 at 8:10 AM revealed she liked to play cards such as Spades and Monopoly. She revealed there were no activities on the weekends and all they did was sit around. The resident explained that during the weekend they (the facility) sometimes had church singing, but she did not like music. She revealed she would like more things to do that she liked. She voiced they (the residents) do have puzzles that were always available, but she was tired of that.

Record review of Resident #41's February 2025 Activity Attendance Record revealed there was no activity participation for the weekend days of the month. Also revealed the resident was marked as participating in outside time (smoking), hall social, watching TV, and being up in her wheelchair.

An interview with Certified Nurse Aide (CNA) #1 on 3/05/25 at 7:55 AM revealed she worked some weekends. She confirmed the facility did not have weekend activities and stated, We sometimes have church members that come sing, but it's not often. She revealed there were no other activities conducted on the weekends.

An interview with Housekeeping #1 on 3/05/25 at 9:18 AM revealed she worked four (4) days on and two (2) days off, which included her working some weekends. She confirmed the facility had no weekend activities and stated, No, they don't do anything.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 255339 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255339 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Choctaw Residential Center 135 Residential Center Rd Choctaw, MS 39350

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Record review of the January, February 2025 activity calendars revealed on the weekends, Independent activities of choice were listed. Level of Harm - Minimal harm or potential for actual harm An interview with the AD on 3/05/25 at 2:30 PM revealed she had been in the activity position for about five (5) years and acknowledged the residents should have activities, including the weekends, which included Residents Affected - Few their likes. The AD revealed Resident #41 liked to play Bingo. She revealed that she included smoking as part of the resident's activity record and hall social, which included social conversation while she was waiting

in the hall to go smoke. She revealed, in her opinion, she had done all she could do to meet the interest of Resident #41.

Record review revealed the Activity Director completed the 40 Hour Basic Activity Director Course dated 11/8/21.

Record review of the Admission Record revealed the facility admitted Resident #41 on 9/6/24 with a medical diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Right Dominant Side.

Record review of the MDS with an ARD of 9/16/24 revealed under, Section C, a BIMS summary score of 13, which indicated Resident #41 was cognitively intact. Also revealed, under section