Pine Forest Health And Rehabilitation

F-F656

During the complaint survey 7/15/24 through 7/18/24, the facility failed to implement comprehensive care plans related to Activities of Daily Living (ADL) care.

During the recertification survey in December 2023, the facility failed to implement comprehensive care plan interventions to ensure residents were clean and dry and nail care was provided to dependent residents.

F-F677

During the complaint survey 7/15/24 through 7/18/24, the facility failed to ensure dependent residents received necessary services to maintain adequate grooming.

During the recertification survey in December 2023, the facility failed to provide adequate and appropriate grooming for residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 255326 Department of Health & Human Services Printed: 09/17/2025 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 255326 B. Wing 07/18/2024

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

Pine Forest Health and Rehabilitation 1116 Forest Avenue Jackson, MS 39206

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 0865 An interview on 7/18/24 at 4:40 PM, with the Administrator revealed the Director of Nurses (DON), Assistant Director of Nurses (ADON) or Registered Nurse (RN) Supervisor completes audits of grooming of residents. Level of Harm - Minimal harm or The He stated grooming includes removal of unwanted facial hair and fingernail care in accordance with the potential for actual harm facility's plan of correction developed as a result of deficiency citations from the December 2023 Annual Survey. The Administrator revealed he had attended QAPI meetings since the annual survey and confirmed Residents Affected - Few audit results were presented to the committee and reviewed. The Administrator stated he felt as if the facility's QAPI program was working but perhaps the facility should have monitored/audited a greater number of residents, given the size and census of the facility to ensure adequate grooming was provided for all residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 255326