Failure to Assign Charge Nurse Leads to Impaired LPN and Missed Medications
Summary
The deficiency involves the facility’s failure to ensure sufficient licensed nursing supervision and coordination of care when no licensed nurse was designated to serve as charge nurse for the night shift beginning at 7:00 PM on 12/29/25. The scheduled charge nurse called in sick, and the daily staffing schedule showed the supervisor for the 7:00 PM–7:00 AM shift marked out with “vacation” and no replacement charge nurse indicated. As a result, there was no nurse assigned to supervise staff, coordinate care, or respond to unsafe conditions on that shift, despite facility policy requiring a licensed nurse to be designated as charge nurse on each tour of duty. During this unsupervised shift, an LPN assigned to Station B reported being ill, later stating in a counseling/discipline report that they had a temperature of 101 degrees and a blood sugar of 67, and that they did not remember the events. The facility’s investigation and camera footage review showed that this LPN remained on duty from 7:00 PM until approximately 3:00 AM while impaired and unable to safely perform nursing duties. The LPN was observed at the nurse’s station for about two hours, then pushing the medication cart into the hallway, staring at the computer for a long time, swaying and almost falling, stumbling, and appearing to be under the influence of something. The LPN fumbled through the medication cart, pulled medication cards and stared at them for minutes, fell asleep at the medication cart in the dining room with their head resting on the cart, and awoke only when the cart began to roll away. A resident in the dining room witnessed this incident, and nursing assistants repeatedly woke the LPN and placed a chair behind them after they nearly fell while sleeping on the cart. Certified nurse assistants on the unit reported that around 8:00 PM the LPN began falling asleep standing up, crying loudly, moaning, and going back and forth to the bathroom frequently. They described the LPN leaning over the medication cart with eyes closed, legs giving out, and falling asleep on the counter in the nurse’s station and at the open medication cart. Staff stated that no residents on that station received their medications as ordered, that residents repeatedly called for their medications, and that the LPN could not stay awake to pull or pass medications, even with assistance from the nurse on the other station who tried to help with the medication pass. One CNA reported the LPN kept falling asleep while trying to sign the narcotics book and refused an ambulance when staff tried to get emergency help. Medication administration audit reports for Station B showed 25 residents with medications documented as missed and 5 residents with medications documented as administered late during this shift. The DON and Administrator later confirmed that there was no designated charge nurse on duty, that the impaired LPN remained responsible for resident care and medication administration until a replacement nurse arrived around 3:00 AM, and that the DON was not notified of the situation until approximately 1:30 AM.
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 that indicate the staff member who tested the temperature of the coffee, the time, and the date.
- Coffee temperature logs will be turned into the Administrator daily.
- Training for all staff 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.
- Staff will be trained on accidents and supervision including implementing immediate interventions.
- Staff will be trained on abuse and neglect reporting and investigation.
- Staff will be trained on the hot liquids policy.
- Staff will be trained on notification of the Administrator and Director of Nursing (DON) of unusual occurrences, high risk events, and timely notification.
- Staff will be trained on charge nurse delegation and duties including assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse.
- If the assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment.
- The DON and Administrator's phone numbers are posted on the Facility Assignment Grid.
- In the event that the charge nurse is impaired, the DON and Administrator will be contacted.
- The Facility Assignment Grid was updated to include assignment for a designated charge nurse.
- Staff will be trained on medication administration documentation.
- All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
- The 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 to include a contingency plan for absence of supervisory nursing staff and adequately identified 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.
- Emergency Quality Assessment and Assurance Committee Meeting held.
- The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made.
- 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 that she works for and is not allowed to work at this facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insufficient nursing staff were present on a unit when a resident who required 2-person assist for ambulation and toileting was found walking from the bathroom to bed alone after waiting for help. At the time, only an LPN and a clerk were observed on the unit, while other NA staff had already punched out and the second nurse was charting on another unit.
Insufficient CNA Staffing and Delayed Resident Care: Residents and staff reported that CNA coverage was inadequate on evenings, nights, and weekends, leading to delayed call light response and unmet care needs. A resident with impaired mobility and another with CVA-related deficits reported long waits for assistance, while a CNA stated she was the only CNA on a hall overnight and had not been able to check many rooms. The Administrator and CNA Supervisor acknowledged staffing shortages, especially on nights and weekends, and resident council and grievance records also documented concerns about short staffing.
Insufficient nursing staffing led to delayed and incomplete resident care. The facility scheduled fewer CNAs than required by its assessment, often leaving only 5 to 6 CNAs on day shift instead of 8, and staff were told to cancel shifts when census dropped. Residents reported long waits for toileting and assistance, including being left in feces and waiting during meals for help, while CNAs described working alone, delayed call light response, missed or delayed ADL care, and difficulty completing 2-person transfers and mechanical lifts.
Delayed response to activated call lights was identified for a resident with intact cognition who required assistance with toileting, transfers, and ambulation and had care plan interventions for impaired mobility, safety, weakness from TIA, and fall risk. The resident reported staff often shut off the call light without providing help, and alarm records showed multiple response times over 15 minutes, including several lasting more than 30 minutes and up to nearly an hour. Staff and the DON acknowledged that response times had exceeded the expected timeframe, and the facility policy required staff to respond to engaged call lights in a timely manner.
A resident with a PEG tube, dysphagia, dementia, epilepsy, and other neurologic conditions had scheduled meds ordered through the tube, but the eMAR showed no meds documented for an entire evening med pass. The RN/UM said she worked a double shift because of a nursing call-out and forgot to document the meds as given, and the DON acknowledged the missed documentation.
Insufficient nursing staffing and delayed call light response were identified after residents reported waits of 30 minutes to 2 hours for assistance, including one resident left in the bathroom for 45 minutes and another with a 55-minute wait after activating a call light. The CNA scheduler said staffing was based on a corporate PPD target of 2.85 hours per resident rather than acuity, and records showed multiple weekend shifts with CNA, UM, and RN call-offs or no-shows. Residents also reported staff sitting in the lounge, not responding to lights, and unmet toileting and care needs.
Insufficient nursing staff on unit
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of every resident and to have a licensed nurse in charge on each shift. During an observation on 7/7/26 from 6:54 a.m. through 7:02 a.m., only LPN Employee E10 and the 2A clerk were observed on the nursing unit, while the resident room bathroom call light for Resident R239 was illuminated. At 7:03 a.m., Resident R239 was observed ambulating from the bathroom to bed by herself and stated she got tired of waiting for help. LPN Employee E10 then went to assist her because there were no other staff on the unit. Resident R239's plan of care identified that she required assistance of two staff for ambulation and toileting. Review of 11 p.m. to 7 a.m. staff punch-out times showed one NA punched out at 6:48 a.m., one NA punched out at 6:58 a.m., and two others punched out with the supervisor at 7:00 a.m.; the first NA for the 7 a.m. to 3 p.m. shift was observed on the unit at 7:02 a.m. During interview, the Nursing Supervisor stated the second nurse for the 2A unit was on 2B charting and no other staff were on the unit. The Nursing Home Administrator later confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident R239.
Insufficient CNA Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs in a timely manner and failed to have enough CNA coverage on evenings, nights, and weekends. The report states the facility had 108 residents and could not provide a staffing policy. Interviews with the Administrator and CNA Supervisor confirmed that nights and weekends were the hardest shifts to fill, that staff shortages were common, and that administrative staff were being used to help cover evening hours when CNA shifts were not fully staffed due to call-ins or no-shows. The CNA Supervisor also stated that optimal staffing on the 200 hall would be two CNAs on all shifts because many residents required two-person assistance with mechanical lifts. Several residents described delayed responses to call lights and assistance needs. One resident with diagnoses including acute respiratory failure, diabetes mellitus, anemia, anxiety disorder, and cognitive communication deficit stated the call light system was not working and that she had been given a whistle to use instead; she reported prolonged waits for staff response, especially after dinner and overnight, and said she had had incontinence episodes while waiting. Another resident with cerebral infarction, hemiplegia, major depressive disorder, and cognitive communication deficit stated she waited longer in the evening and overnight when using the call light, and that weekends seemed to have less staff available. A family member present during that interview stated staff worked hard but did not have enough help, especially on second shift and weekends. A third resident with anemia, muscle weakness, and need for assistance with personal care stated her call light system did not work and she had been given a dinner bell to use when needing assistance. She reported waiting 30 minutes or more for help with her incontinence brief during evening and overnight hours. A CNA working the night shift stated she was the only CNA assigned to the 200 hall at that time, that only 5 CNAs total were working nights including the supervisor, and that she had only checked 4 rooms since arriving before 2:00 AM, with 8 rooms or 11 residents still not checked on her hall. Resident council minutes also documented concerns that there were not enough CNAs on weekends, and a grievance form documented a resident complaint about not receiving a shower due to short staffing.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff in accordance with its facility assessment and residents’ care needs. The assessment called for 1 RN, 2 LPNs, and 8 CNAs on day shift; 3 LPNs and 8 CNAs on evening shift; and 3 CNAs plus 2 additional staff on night shift. However, the nursing schedule from June 2026 through July 3, 2026, showed no days with 8 CNAs assigned to the day or evening shift, with day shift typically staffed by only 5 to 6 CNAs. On one day, a note next to two staff names stated, “If all show, go home,” leaving only 5 CNAs on the floor. On another day, one CNA called off and was not replaced, leaving 3 CNAs for the 100-400 units and 1 CNA for the villa. Residents and staff described delays in care and difficulty meeting basic needs because of the staffing levels. One resident, who had multiple diagnoses including multiple sclerosis, trigeminal neuralgia, convulsions, malnutrition, COPD, hypotension, and epilepsy, was dependent on staff for ADLs and reported being left in feces for 45 minutes because no one was available to assist. The resident also reported that during meal times, call lights were not answered until meals were finished because aides were feeding residents and no one else was available. Another resident, who was dependent on staff for ADLs and had diagnoses including hemiplegia, chronic pain, depression, and falls, stated that the facility was short-staffed and that CNAs were stressed and unable to perform their jobs as they should. Multiple CNAs and the DON confirmed the staffing shortages and the effect on resident care. CNAs reported working alone in the villa, being told no additional CNA would be assigned until census exceeded 18, waiting for help with two-person transfers and mechanical lifts, delayed call light response times of up to 25 minutes, and residents being left soaked in urine overnight because there was not enough staff. The DON stated he wanted additional nurses and CNAs but was told to cancel staff when census dropped. The facility’s fall list also showed an increase in unwitnessed falls from 3 in May 2026 to 15 in June 2026.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to consistently respond to activated call lights within a timely manner for one resident. Resident #47 had a BIMS score of 15 out of 15 and required partial/moderate assistance with toileting hygiene and toilet transfers. The resident’s care plan identified impaired mobility, safety concerns, functional performance deficits related to weakness from a transient ischemic attack, and risk for falls, with interventions directing staff to keep the call light within reach, encourage use of it for assistance, and provide prompt response to requests for help. During observation, Resident #47 stated the call light had been activated for several minutes and was shut off by staff without assistance being provided, and the resident reported this happened often. Staff F acknowledged shutting off the call light when unable to assist the resident to the bathroom. Review of the facility’s excess response alarms showed multiple call light response times for Resident #47 ranging from 16.7 minutes to 57.3 minutes. Staff interviews confirmed that an appropriate response time was under 15 minutes, and the DON acknowledged that call lights had exceeded 15 minutes at times. The facility policy stated all staff were to respond to an engaged call light to rule out an emergency situation and that resident needs such as transfers, toileting, and dressing were to be addressed in a timely manner.
Missing Medication Documentation After Short-Staffed Shift
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure that medications and treatments were properly documented for one resident. Resident #47 had diagnoses including late effects of cerebral infarction, aphasia following cerebral infarction, dysphagia, dementia, epilepsy, hypertension, and gastrostomy status. The resident’s MDS indicated the resident was rarely or never understood and had a tube feeding. Physician orders included multiple scheduled medications administered via PEG tube and enteral feeding orders. Review of the eMAR for the evening shift showed no medications documented as administered for the entire medication pass. The medical record did not contain a nursing progress note explaining that the resident was out of the facility, refused medications, or otherwise accounting for the missing documentation. The RN/UM stated she worked a double shift because of a nursing call-out and, while working as the med nurse, forgot to document that the medications had been administered during the evening shift. The DON acknowledged that the RN/UM had worked two consecutive shifts due to a call-out and forgot to document administering the resident’s medications during the evening med pass.
Insufficient Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and failed to ensure a licensed nurse was in charge on each shift. During a confidential resident group meeting, residents reported that call light response times were commonly about 30 minutes, could be as long as two hours, and that one resident had been left in the bathroom for 45 minutes before yelling for help. Residents also stated that the facility needed more staff and that staff called in too often. During interviews and record review, the surveyor learned that the facility used a corporate per-patient-day guideline of 2.85 hours per resident and did not use resident acuity in scheduling. The CNA/staff scheduler stated that management did not want staffing to go over or under that target and that she scheduled as close to it as possible. She also stated that weekend staffing was stacked to anticipate call-offs, and that residents had reported only one CNA on night shift, although she said clock-in records did not show that. She further stated that 3rd shift staff were in the lounge watching TV and not responding to call lights, and that the cameras did not work. Payroll and staffing records showed multiple weekend shifts with call-offs and short staffing across CNA, unit manager, and licensed nurse shifts, including several dates with multiple call-ins or no-shows on 1st, 2nd, and 3rd shifts. Residents reported long waits for call lights, unmet toileting needs, and staff not responding or returning after entering rooms. One resident’s concern form documented a 55-minute wait after a call light was activated, and another resident stated that staff did not respond for 30 minutes to 3 hours. The DON, regional clinical consultant, and NHA all acknowledged that PBJ staffing was submitted at the corporate level, and the NHA was aware of excessively low weekend staffing that had triggered in March 2026.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 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.