Tunica County Health & Rehab, Llc

F-F580

Review of the policy titled , End-Stage Renal Disease, Care of a Resident with, revealed agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including the facility will share pertinent information with the dialysis unit on residents per communication.

Review of the E-Medication Administration Record (EMAR) from June 4th -June 17th for Resident #46, revealed Cosopt eye drops: instill one drop to both eyes twice daily for Glaucoma-(6) six refused doses. Docusate Sodium 100 (mg) milligram twice daily for prevention of constipation-12 refused doses. Pepcid 20 mg one tablet twice daily for GERD (Gastroesophageal Reflux Disease) -(5) five refused doses. Aspirin 81 mg one tablet daily for history of CVA (Cerebral Vascular Accident)-5 refused doses. Plavix 75 mg 1 tablet daily for Peripheral Vascular Disease--5 refused doses. Vitamin C 500 mg daily to promote wound healing--5 refused doses. Zinc 50 mg daily to promote wound healing--5 refused doses.MTV (multivitamin) with minerals one tablet daily to promote wound healing--5 refused doses.Rena Vite one tablet daily for ESRD (End Stage Renal Disease) --5 refused doses.Norvasc 10 mg one tablet daily on Tuesday/Thursday/Saturday /Sunday-(4) four refused doses. Sodium Bicarb 650 mg 2 tablets twice daily for ESRD-10 refused doses. Pro-stat 30 (ml) milliliters twice daily to promote wound healing- 22 refused doses. Arginaid 1 packet twice daily to promote wound healing-22 refused doses.Velphoro 500 mg 1 tablet three times daily for ESRD- 20 refused doses.

Review of the June Dialysis Transfer forms for Resident #46, revealed no documentation of resident refusing medications on multiple days.

An interview with Resident #46 on 6/19/24 at 9:00 AM, revealed she knows she does not take all her medications but takes them when she is feeling up to it. She knows she needs to take them.

An interview with the Director of Nursing (DON) on 6/18/24 at 10:00 AM, she verbalized after review of the June 2024 Dialysis Transfer Forms for Resident #46 she was unable to find any documentation that the dialysis clinic was ever notified of the resident's refusal of medications and supplements. She then stated the Dialysis Provider should have been notified of Resident #46's continued refusal of medications and failure to do so put the resident at risk for decompensation, organ failure, or acute illness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 255334 Department of Health & Human Services Printed: 09/23/2025 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 255334 B. Wing 06/19/2024

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

Tunica County Health & Rehab, LLC 1024 Highway 61 South Tunica, MS 38676

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 0698 A phone interview with the Dialysis Registered Nurse (RN) #1 on 6/19/24 at 5:45 AM, verbalized Resident #46 was a patient at the clinic and she is assigned to her. She verbalized she was not aware that Resident Level of Harm - Minimal harm or #46 had not been taking her medications and supplements, and that information was not on any of the potential for actual harm communication forms sent from the nursing facility. She stated Resident #46's treatment plan was discussed

on the morning of 6/18/24 with the Nephrologist and care team and the refusal of medications should have Residents Affected - Few been discussed for needed changes. She went on to say that she will immediately ensure the provider and care team are aware because the provider may need to make changes to Resident 46's treatment plan. She went on to reveal that the refusal of the medications and supplements could definitely affect Resident #46's lab values and overall health condition.

An interview with Licensed Practical Nurse (LPN) #2 on 6/19/24 at 8:10 AM, she verbalized she was aware that Resident #46 had been refusing her medications and verbalized that Resident #46 was continuing to refuse her medications and vitamin supplements. LPN #2 confirmed she had not communicated to dialysis that the resident was continuing to refuse her medications and confirmed she should have.

Review of the Face Sheet revealed the facility admitted Resident #46 on 4/30/24 with a diagnosis of End Stage Renal Disease and Orthopedic aftercare following a surgical amputation.

Record review of the Admission Minimum Data Set (MDS) Section C with an Assessment Reference Date) ARD of 5/07/24, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated she was moderately cognitively impaired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 255334 Department of Health & Human Services Printed: 09/23/2025 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 255334 B. Wing 06/19/2024

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

Tunica County Health & Rehab, LLC 1024 Highway 61 South Tunica, MS 38676

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 47158

Residents Affected - Few Based on observation, staff interview, record review, and facility policy review, the facility failed to store food

in accordance with professional standards for food safety as evidenced by failure to maintain the cleanliness of a resident's personal refrigerator for one (1) of 16 resident refrigerators observed. Resident #8.

Findings include:

A record review of the facility policy titled, Food brought by Family/Visitors/Outside Sources, revised January 2018, revealed foods requiring refrigeration may be stored in a resident's personal refrigerator. A designated employee will be assigned the following task, keeping the refrigerator clean and free from spills.

A record review of the facilities Night shift wheelchair and refrigerator schedule revealed Thursday, clean refrigerators in your assigned group.

An observation of Resident #8's refrigerator with Licensed Practical Nurse (LPN) #1 on 6/18/24 at 10:00 AM, revealed 1 quarter sized and two (2) nickel sized black spots were noted in the top compartment of the refrigerator door and numerous small black spots were covering the entire bottom of the refrigerator. The refrigerator was also noted to contain 2 fruit cups and four (4) bottles of water. LPN #1 identified the black spots as mildew and stated that the refrigerator was extremely nasty. She stated that the refrigerator should be cleaned weekly by staff but confirmed the refrigerator had not been cleaned in a while.

In an interview with the Director of Nursing (DON) on 6/18/24 at 11:00 AM, she revealed that staff informed her of how dirty Resident #8's refrigerator was and stated the refrigerators are scheduled to be cleaned weekly on night shift. She stated there is no documentation log for staff to sign when the task is completed.

The DON stated the refrigerator not being cleaned and having mildew present could place the resident at risk for getting sick with a foodborne illness.

In an interview with the Infection Preventionist (IP) on 6/19/24 at 8:45 AM, she stated that she did not check to ensure that resident refrigerators were cleaned as scheduled and there was no way to know exactly when Resident #8's refrigerator was last cleaned.

A record review of Resident #8's Face Sheet revealed the facility admitted him on 10/10/2018 with a diagnosis of Dementia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 255334