Grand Trace Health And Rehabilitation

F-F641 - Significant Change Assessment

During the recertification survey, the facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who returned from the hospital with two significant changes.

F-F677 - ADL Care

During the recertification survey conducted on 03/07/2024, the facility failed to provide Activities of Daily Living (ADL) care to a dependent resident.

F-F725 - Sufficient Staffing

During the recertification survey, the facility failed to provide sufficient staffing to meet residents' care needs.

On 03/27/25 at 2:12 PM, during an interview with the Corporate Nurse (CN) and the Interim Nursing Home Administrator (INHA), the INHA stated he had been in the facility for three (3) weeks and was aware of the past survey results. He stated the facility had conducted QAPI meetings to address the repeated citations.

The CN acknowledged awareness of the repeated concerns and explained that they stemmed from the facility's noncompliance with regulations. The CN stated the facility had held both QAPI and Performance Improvement Project (PIP) meetings related to these concerns and now conducts QAPI meetings monthly.

The CN also stated that the QAPI policy is reviewed annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 255173 Department of Health & Human Services Printed: 09/03/2025 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 255173 B. Wing 03/27/2025

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

Glenburney Health Care and Rehabilitation Center 555 John R. Junkin Drive Natchez, MS 39120

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50751 potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to implement Residents Affected - Few appropriate infection prevention and control practices during medication administration for one (1) of one (1) medication pass observations (Resident #169).

Findings included:

Record review of the facility policy titled Administering Medication, dated April 2019, revealed Medications are administered in a safe and timely manner and as prescribed . 25. Staff follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable .

On 03/26/25 at 8:45 AM, during the administration of morning medications to Resident #169, Licensed Practical Nurse (LPN) #2 was observed entering the resident's room. The resident asked to see the medications prior to taking them. At this time, the nurse poured the medications into her bare, ungloved hand, and the resident proceeded to take the medications after inspecting them.

On 03/26/25 at 8:55 AM, during an interview, LPN #2 confirmed she had placed the medications into her ungloved hand and stated she should have worn gloves during the exchange to prevent contamination. She acknowledged it posed a risk of spreading infection to the resident, particularly since she had not performed hand hygiene before entering the room.

On 03/27/25 at 10:40 AM, during an interview with the Infection Prevention (IP) Nurse, LPN #1, she explained that the nurse should have worn gloves prior to handling the resident's medications. She stated gloves are necessary to prevent spreading infections, including respiratory illnesses, to residents.

On 03/27/25 at 10:56 AM, during an interview with the Corporate Nurse, she stated the nurse should have either discarded the contaminated medications and replaced them with new, uncontaminated ones or worn gloves prior to handling them. She explained that staff could transmit infections and bacteria to residents when medications are contaminated due to improper handling or lack of hand hygiene. She stated it was her expectation that staff follow basic infection control guidelines during medication administration.

A record review of Resident #169's Admission Record revealed the facility admitted the resident on 03/22/25 with diagnoses including Functional Quadriplegia, Generalized Anxiety Disorder, and Low Back Pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 255173