Failure to Protect Residents From Hot-Liquid Burn Hazard and Care by Impaired Nurse
Summary
The deficiency involves the facility’s failure to protect residents from neglect in two primary areas: exposure to a known hot-liquid burn hazard and allowing an impaired nurse to remain responsible for resident care and medication administration. On one occasion, a resident with dementia and a severely impaired BIMS score of 03 sustained a burn to the left hip/thigh area when another resident gave him hot coffee, which was then spilled, causing blisters and a new in-house skin issue measuring 7.06 cm by 7.56 cm. The incident report documented that the resident cried out in pain, and subsequent emergency department documentation confirmed the burn was from a coffee spill at the facility. Despite this event, residents continued to have access to hot coffee in the dining room without supervision, temperature controls, or access restrictions for nearly two weeks. The facility also failed to intervene appropriately when an LPN on the night shift was impaired and unable to safely perform nursing duties. Staff statements and camera footage showed the nurse repeatedly falling asleep standing up, leaning over the med cart with eyes closed, crying loudly, moaning, swaying, stumbling, and nearly falling. CNAs reported that residents were calling for their medications, that the nurse fell asleep at the med cart and on the counter in the nurse’s station, and that she repeatedly went to the bathroom for long periods. The DON was notified by another nurse at 1:30 AM that the impaired nurse could not complete the med pass and kept falling asleep, but the impaired nurse remained in the building and responsible for resident care until approximately 3:00–3:30 AM. There was no designated charge nurse on that shift after the scheduled charge nurse called in sick, and no nurse was assigned to supervise staff, coordinate care, or respond to the unsafe condition. Medication administration records and audit reports showed that multiple medications were either not documented as given or were documented late for residents on the impaired nurse’s unit. For four sampled residents, there was no documentation that scheduled evening and bedtime medications were administered on the night in question, including Donepezil for dementia, Crestor, Latanoprost, Novolog, Trazodone, Gabapentin, Duloxetine, Keppra, Lacosamide, and ordered accuchecks. One cognitively intact resident reported being in the dining room, observing that the nurse appeared impaired and unable to safely administer medications, and stated he did not receive his medications and would have been afraid to take them from her. Another cognitively intact resident reported that his medications and blood sugar check were not done and that a CNA told him something was wrong with the nurse. The facility’s own medication administration audit identified 25 residents with missed medications and 5 residents with late medications on that unit during the relevant time frame, and staff confirmed that another LPN pulled medications for the impaired nurse without observing administration, verifying correct resident, or documenting on the MAR, while the impaired nurse retained responsibility and control of narcotic keys. The Administrator acknowledged awareness that the impaired nurse remained on duty until a replacement arrived and that he was not informed of the coffee burn incident until several days after it occurred. He confirmed that, although leadership discussed modifying the coffee service process after he learned of the burn, he did not verify that any changes were implemented or monitored. When surveyors arrived, they were able to obtain hot coffee directly from a dining room machine that was still operational despite signage indicating it was out of service, and the Administrator acknowledged that residents had continued access to hot coffee and that no system had been in place to ensure the discussed intervention was followed. The State Agency determined that these failures to safeguard residents from a known burn hazard and to remove an impaired nurse from resident care created Immediate Jeopardy and substandard quality of care under F600, beginning when residents remained under the care of the impaired nurse.
Removal Plan
- Coffee machines were removed out of service by the Maintenance Director.
- Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
- Coffee temperature logs were created to indicate the staff member who tested the temperature of the coffee and the time.
- Coffee temperature logs will be turned into the Administrator daily.
- Training for all staff will be completed prior to their next scheduled shift.
- No staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse.
- Training will include: accidents and supervision including implementing immediate interventions; abuse and neglect reporting and investigation; hot liquids policy; notification of Administrator and DON of unusual occurrences/high risk events and timely notification; charge nurse delegation and duties including assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse and process if assigned charge nurse calls off; posting DON and Administrator phone numbers on the Facility Assignment Grid; requirement to contact DON and Administrator if charge nurse is impaired; updated Facility Assignment Grid to include designated charge nurse; medication administration documentation.
- All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
- Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
- The Facility Assessment was updated by the Administrator to include a contingency plan for absence of supervisory nursing staff and to identify staffing needs by shift and building.
- The facility's Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
- The Scheduler and the Staff Development Nurse were inserviced by the DON on the new Assignment Grid and charge nurse delegation.
- The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
- All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
- An emergency Quality Assessment and Assurance Committee meeting was held to review the Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy and to discuss the incident summary, actions taken, training, and monitoring.
- The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving LPN #1.
- LPN #2 was reported to the agency she works for and is not allowed to work at this facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.