Failure to Maintain Adequate Staffing Assessment and Contingency Plan During Influenza Outbreak
Summary
The facility failed to ensure its facility-wide assessment contained the required details regarding staffing needs by shift and by unit, and did not maintain an actionable contingency plan for staffing emergencies. The assessment only included hours per resident day (HPRD) rather than specifying the number of licensed nurses and CNAs needed per shift and per unit. During an influenza outbreak, the facility did not update the assessment or contingency plan to address the increased risk and staffing needs, and administrative staff were used to assist with care when a nurse called in sick, but no agency staff were used and no formal process was in place to secure additional coverage. On the night in question, only one nurse was responsible for 58 residents from midnight until 7 AM, resulting in missed medications and inadequate monitoring for residents on one unit. The administrator and DON were aware of the staffing shortage and attempted to contact other nurses, including those at sister facilities, but were unable to secure additional coverage. The administrator assisted at the nursing station, but the facility's contingency plan did not provide clear procedures for securing coverage during emergencies or staff call-offs, and no updates were made to the plan following the incident. The facility did not identify the influenza outbreak when three residents tested positive, did not initiate droplet precautions, notify the health department, provide timely antiviral treatment, or maintain outbreak surveillance and staff illness tracking. The facility also failed to use its QAPI program to identify and correct system failures in infection control and staffing during the outbreak. These failures resulted in the facility being unprepared for staff absences during the influenza outbreak, placing all residents at risk for serious illness, harm, impairment, or death.
Removal Plan
- The Administrator held an emergency Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse, and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for QAPI for any changes needed and as re-education in policy.
- The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies.
- Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building.
- The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist.
- Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies.
- The Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications.
- The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
- The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
- Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in-service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
- The Administrator reviewed policy on QAPI plan and policy for re-education purposes and to review new policy. The QAPI plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up QAPI meeting.
- The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
- The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
- The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
- The Administrator notified the Mississippi Department of Health of the flu outbreak.
- The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Update Facility Assessment Annually: The facility failed to conduct and document an annual facility-wide assessment to determine resources needed to care for residents competently. Record review showed the Facility Assessment had not been updated since January 2025. The AIT and Interim ADM both stated they had not reviewed the assessment after assuming their roles and acknowledged it should be reviewed and updated annually or when significant changes occurred.
Facility Assessment Missing Staffing and Resource Details: The facility failed to complete a Facility Assessment with the required details on staffing decisions, specific staffing needs by unit and shift, staff competencies, and a plan to maximize recruitment and retention of direct care staff. The assessment also lacked evidence of the resources needed for competent resident care during routine operations and emergencies. The ADMN stated she used the prior administrator’s assessment as a template and was unaware these items needed to be included; the facility also had no policy for the Facility Assessment.
Facility Assessment Not Updated for Lack of RT Contract: The facility failed to update its Facility Assessment after it no longer had an active RT contract. The assessment still listed RT as a needed resource, while the Admin confirmed there was no contracted RT company in place and acknowledged the assessment should be updated annually and as needed.
Incomplete Facility Assessment With Blank Nurse Staffing Section: The facility failed to complete and document a facility-wide assessment used to staff the facility, leaving the nurse staffing section blank. The Administrator stated she had not updated the assessment based on census, and the RCN stated residents were at risk of not receiving timely care. The facility also stated it did not have a facility assessment policy it followed.
The facility failed to complete and document a comprehensive facility-wide assessment for resident care needs during routine operations and emergencies. The 2025 Facility Assessment was signed by former leadership, referenced a missing Staffing and Personnel Worksheet, listed prior admin and DON staff, and contained multiple sections stating no records were found. The facility also could not provide evidence of a plan to maximize recruitment and retention of direct care staff, and the DON acknowledged the assessment did not accurately reflect staffing patterns.
Facility Assessment Not Reviewed Annually: The facility failed to review and update its Facility Assessment annually. The ADON confirmed the assessment had not been updated or reviewed since 2023, despite 77 residents in the facility, and stated there was no policy on Facility Assessment. The Administrator was unavailable for interview initially and later said he thought the assessment had been reviewed last year.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for residents competently during day-to-day operations and to review and update the assessment at least annually for 1 of 1 facility reviewed. Record review showed the Facility Assessment had not been updated since January 2025. A facility policy titled Facility Assessment, revised October 2018, stated that a facility assessment is conducted annually to determine and update the facility’s capacity to meet resident needs and competently care for residents during day-to-day operations, and that the assessment is reviewed and updated annually and as needed. During an interview on 06/30/26 at 1:59 PM, the AIT stated she had served in that role since July 2025 and had not reviewed the Facility Assessment since assuming the position because she had not had time. She stated it had been updated before the previous survey and acknowledged it was her responsibility along with the ADM to update the Facility Assessment and that it should be reviewed and updated annually or whenever significant changes occurred. She stated the only changes since the last update had been administrative leadership changes and said she would update the assessment that day with assistance from the Interim ADM. During an interview on 06/30/26 at 2:55 PM, the Interim ADM stated she had been employed at the facility since February 2026, had not reviewed the Facility Assessment upon assuming her position, and was unsure when it had last been updated. She stated she believed it was her responsibility to update the assessment annually or when changes occurred and thought it had already been updated during 2026.
Facility Assessment Missing Staffing and Resource Details
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that identified the resources needed to care for residents competently during daily operations and emergencies. The Facility Assessment, dated 01/05/2026, contained no evidence of the resources needed to provide competent resident support and care, staff training and education, staff competencies, staff assignment needs, or a plan to maximize recruitment and retention of direct care staff. The assessment was reviewed by QAPI on 01/23/2026, and no governing body member was present. Record review of the Resident Matrix, dated 06/29/2026, showed a census of 59 residents, including 17 residents with falls, 3 residents with pressure ulcers, 3 residents with infections, and 1 resident who used an enteral tube for nutrition and medication administration. During interview, the ADMN stated she was responsible for completing the Facility Assessment and had used the prior Administrator’s assessment as a template. She stated she was unaware the assessment needed to include staffing decisions, how staffing needs were determined, or how the facility planned to retain staff. She also stated the facility did not have a policy regarding the Facility Assessment.
Facility Assessment Not Updated for Lack of RT Contract
Penalty
Summary
The facility failed to implement its policy and procedure titled Facility Assessment when it did not update the assessment after it no longer had a contracted Respiratory Therapy (RT) company. The facility assessment, dated 1/27/2026, still indicated RT as a resource needed by the facility, even though the Administrator stated during interview that there was no active RT contract in place and that it was not appropriate to include RT in the assessment without one. During concurrent interview and record review on 6/26/2026 at 1:40 p.m., the Administrator reviewed the Facility Assessment and confirmed the facility did not have an active contracted RT company. The facility’s policy titled Facility Assessment, dated 1/2026, stated the assessment should be reviewed and updated as necessary and at least annually whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment.
Incomplete Facility Assessment With Blank Nurse Staffing Section
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies. Record review of the facility assessment dated [DATE] showed that the assessment was incomplete and was being used to staff the facility, with the nurse staffing section left blank. The blank section was supposed to identify the number of licensed nurses and certified nurse aides needed on the day shift and night shift based on the facility census and acuity of care needs. During an interview on 06/25/2026 at 12:30 p.m., the Administrator stated she had been working at the facility for 2 weeks and had not updated the facility assessment. She stated it was the Administrator’s responsibility to complete and update the assessment according to census and said she had not had time to update it, although she had a prior copy dated 12/31/2025. She acknowledged that the prior assessment was incomplete with the nurse staffing portion left blank. During an interview on 06/25/2026 at 1:30 p.m., the RCN stated that a completed facility assessment was provided after surveyor intervention, expected the Administrator to keep it updated in accordance with census, and stated residents were at risk of not receiving timely care. The RCN also stated the facility did not have a facility assessment policy that they follow.
Facility Assessment Not Updated to Reflect Staffing Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. Review of a community-reported complaint alleged a severe and persistent staffing shortage at the facility. Review of the 2025 Facility Assessment showed it was signed by the former administrator and former DNS on 3/30/2026, and it referenced a Staffing and Personnel Worksheet that was not found in the attachments. Multiple supporting document sections stated, "No records were found." The assessment also listed previous employees as the administrator and DNS rather than the current administrator and DNS. The facility also failed to provide evidence of a plan to maximize recruitment and retention of direct care staff. During interview, the DNS acknowledged that the Facility Assessment did not accurately reflect the staffing patterns of the facility and could not provide evidence of a recruitment and retention plan for direct care staff.
Facility Assessment Not Reviewed Annually
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine the resources needed to care for residents competently during day-to-day operations and emergencies because the Facility Assessment was not reviewed or updated annually. The facility census dated 6/9/26 showed 77 residents residing in the facility, and the Facility Assessment had last been revised and updated on 7/31/23. On 6/10/26 at 2:00 PM, the ADON stated the Administrator was responsible for updating and reviewing the Facility Assessment annually and confirmed it had not been updated or reviewed since 2023. The ADON also stated the facility did not have a policy on Facility Assessment. The Administrator was not available for interview on 6/10/26 or 6/11/26, and on 6/15/26 at 12:00 PM, the Administrator said he thought the Facility Assessment was reviewed last year.
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