Failure to Maintain Facility Assessment and Ensure Supervisory Coverage Resulting in Impaired Nurse Providing Care and Missed Medications
Summary
The deficiency involves the facility’s failure to maintain and update a facility-wide assessment that accurately identified staffing, supervisory, and coordination-of-care needs by shift, including contingency planning for the absence of supervisory nursing staff. The facility assessment, dated in November 2024, identified residents requiring medication administration, supervision, and safety monitoring but was not updated annually as required. It did not specify staffing and supervisory needs by shift, nor did it include safeguards or contingency plans for when required nursing staff, including supervisory staff, were absent. The Administrator acknowledged that staffing decisions were generally based on census and daily schedules and could not explain how the facility assessment was used to determine supervisory coverage or continuity of care when staffing changes occurred. The DON also could not identify a contingency plan in the assessment for staffing needs when there was a staff call-off. On the night shift beginning at 7:00 PM on 12/29/25, the scheduled charge nurse called in sick, and no replacement charge nurse was designated. As a result, there was no licensed nurse assigned as charge nurse to supervise staff, coordinate care, or respond to unsafe conditions on that shift. During this same shift on Station B, an LPN assigned to provide care and administer medications was impaired and unable to safely perform nursing duties. Camera footage reviewed by the DON showed the LPN at the nurse’s station and at the medication cart for an extended period, swaying, stumbling, appearing under the influence, repeatedly falling asleep, and failing to complete the medication pass. Staff statements described the LPN crying loudly, going to the bathroom frequently, falling asleep standing up and at the medication cart, and being unable to stay awake to pull or pass medications. Because there was no designated charge nurse and no clear contingency plan, staff relied on informally notifying the nurse on the other unit, and the DON was not contacted until 1:30 AM. The impaired LPN remained in the facility and under the care of residents until approximately 3:00 AM. Medication Administration Record (MAR) and audit reviews showed that multiple residents on Station B did not have medications documented as administered or had medications documented as given late. For example, one resident with dementia and a severely impaired BIMS score of 3 had no documentation of receiving a scheduled bedtime dose of Donepezil. Another cognitively intact resident with cerebral infarction, hyperlipidemia, glaucoma, diabetes mellitus, and insomnia had no documentation of receiving scheduled evening and bedtime medications, including Crestor, Latanoprost, Novolog, and Trazodone. A resident with hemiplegia following cerebral infarction, diabetes, neuropathy, cough, and seizure disorders had no documentation of receiving any scheduled evening medications, including Keppra and Lacosamide. A resident with senile degeneration of the brain, dementia, hypertension, depression, and neuropathy had no documentation of receiving scheduled evening medications, including Clonidine, Duloxetine, and Gabapentin. Medication administration audit reports for Station B showed 25 residents with missed medication administrations and 5 residents with late medications during this period. The situation was determined to be Immediate Jeopardy beginning at 7:00 PM on 12/29/25 due to the lack of supervisory licensed nurse coverage and the continued care by an 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 monitored by the Dietary Department to ensure coffee served is at or below 140°F.
- Coffee temperature logs were created to document the staff member who tested the coffee temperature and the time; 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 (topics include accidents/supervision and immediate interventions, abuse/neglect reporting and investigation, hot liquids policy, notification of Administrator/DON of unusual occurrences/high-risk events and timely notification, charge nurse delegation/duties and assignment process, impaired charge nurse escalation, updated facility assignment grid including designated charge nurse, and 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 adequately 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.
- Emergency QAA Committee meeting held with interdisciplinary attendance (Medical Director via telephone) to review the Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy and discuss the incident, actions taken, training, and monitoring.
- The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator regarding 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:
Facility Assessment failed to identify the staffing resources needed from 11:00 P.M. to 7:00 A.M. Review showed the assessment addressed staffing needs only from 7:00 A.M. to 11:00 P.M., and the Administrator confirmed the overnight gap during interview. The issue was found during a complaint investigation and had the potential to affect all 64 residents.
Facility Assessment Missing Staffing and Contingency Planning Details: The facility failed to include specific staffing needs per unit and shift, a plan to support recruitment and retention of direct care staff, and a contingency plan for events that could affect resident care without activating the emergency plan. The Facility Assessment also lacked a total calculation of hours worked per shift and a list of personnel in house to meet resident needs, and the DON/Administrator confirmed these omissions during interview.
Facility Assessment Did Not Reflect Locked Memory Care Unit or Resident Needs. The facility failed to update its Facility Assessment after opening a locked memory care unit on B-Wing for residents with dementia or wandering tendencies. The assessment did not identify the unit, the 34 residents living there, or the services, staffing, competencies, and resources needed to meet resident needs, including resident acuity, cognitive impairment, and behavioral or physical health needs. The NHA confirmed the assessment was incomplete.
Facility Assessment Lacked Specific Staffing Determinations: The facility failed to complete a comprehensive, facility-specific assessment identifying the staffing resources needed to care for residents based on census and acuity. The assessment listed a high-need resident population, including residents needing ADL help, maximal assistance, psychiatric/mood care, neurological care, anticoagulation monitoring, and Memory Care supervision, but only used general statements about staffing based on acuity and hours per patient day. It did not specify required numbers or ratios of CNAs, RNs/LPNs, management, or ancillary staff, nor did it document staffing needs by shift, unit, or changing resident needs.
The facility failed to ensure its facility assessment identified specific staffing needs for each resident unit for a census of 72 residents. The assessment listed overall direct care staffing for day, evening, and night shifts, but it did not break down staffing needs by resident unit. An HR director confirmed that the assessment did not include unit-specific staffing.
Facility Assessment was incomplete because it did not include resident acuity, diseases, conditions, physical or behavioral health needs, cognitive status, or special treatments and conditions. It also did not list the number of nurse aides needed for the day, evening, and night shifts. The Administrator stated the acuity information and CNA staffing numbers had been overlooked and that the assessment was meant to guide staffing based on resident need.
Facility Assessment Did Not Address Overnight Staffing Needs
Penalty
Summary
The facility failed to ensure a comprehensive Facility Assessment was developed to identify the staffing resources needed to provide care for residents competently during day-to-day operations and emergencies. Review of the Facility Assessment, updated 01/25/26, showed that it addressed staffing needs from 7:00 A.M. until 11:00 P.M., but it did not identify the staffing resources needed from 11:00 P.M. until 7:00 A.M. The facility census was 64 residents, and the deficiency had the potential to affect all 64 residents. During an interview on 05/07/26 at 2:40 P.M., the Administrator verified that the Facility Assessment identified staffing resources for 7:00 A.M. until 11:00 P.M. but did not identify staffing resources for 11:00 P.M. until 7:00 A.M. This was an incidental finding discovered during the complaint investigation.
Facility Assessment Missing Staffing and Contingency Planning Details
Penalty
Summary
The facility failed to ensure that its facility assessment included information related to staffing levels needed for specific shifts, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for events that do not require activation of the facility emergency plan but still have the potential to affect resident care. The report states that the facility census was 62 residents, and the deficiency had the potential to affect all residents who resided in the facility. A record review of the facility’s undated Facility Assessment policy showed that the assessment was intended to address resident population, staff competencies and skill sets, physical environment, equipment and services, cultural, ethnic, and religious factors, and facility resources, and to inform staffing decisions, including specific staffing needs per unit and each shift, recruitment and retention planning, and contingency planning for non-emergency events. However, the Facility Assessment dated [DATE] contained no information related to specific staffing needs per unit and each shift, no total calculation of hours worked per shift, no plan for staff development or retention, and no contingency plan for events that could affect residents without activating the emergency plan. During interview on 05/21/2026 at 7:20 AM, the Administrator confirmed that the assessment did not include specific staffing needs per unit per shift, did not list specific personnel in house to meet resident needs, did not cover staffing levels with numbers of staff needed for each shift, and did not include recruitment, retention, or contingency planning.
Facility Assessment Did Not Reflect Locked Memory Care Unit or Resident Needs
Penalty
Summary
The facility failed to conduct and update a facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. Review of the current floor plan showed the B-Wing residential section outlined in red, and the Nursing Home Administrator stated this indicated a locked unit. The facility had created and opened a locked memory care unit for residents with dementia or wandering tendencies on November 4, 2025. Observation of the B-Wing from May 19, 2026, through May 21, 2026, showed the unit doors were locked, required a security code for entry and exit, and sounded an audible alarm when opened after the code was entered. The facility’s matrix identified 34 residents residing on the B-Wing. Review of the Facility Assessment, last reviewed on March 3, 2026, showed it did not identify the locked memory care unit or the specific services, staffing, and resources needed to meet the individual and collective needs of the residents on that unit. The assessment also did not include comprehensive data about the current resident population, including disease types, conditions, physical and behavioral health needs, cognitive impairments, and overall acuity. It further failed to identify how increased resident acuity affected staffing needs, workload, supervision, and the time required to provide basic care, and it did not evaluate the overall number of staff or the competencies and skill sets needed to ensure qualified staff were available to meet resident needs. During interview, the NHA confirmed the Facility Assessment did not contain all required information related to the facility’s current resident population, services, and staffing resources.
Facility Assessment Lacked Specific Staffing Determinations
Penalty
Summary
The facility failed to conduct and document a comprehensive, facility-specific assessment that identified the staffing resources needed to care for residents competently during routine operations and emergencies. The assessment reviewed on 5/18/26 showed an average resident population of 185 admissions/stays, including 106 ongoing stays and 134 long-stay residents, with significant care needs including 99 residents requiring ADL assistance, 89 residents needing maximal assistance or help from two or more staff, 125 residents with psychiatric/mood diagnoses, 102 residents with neurological conditions, 166 residents requiring anticoagulation monitoring, and residents on a designated Memory Care Unit requiring specialized dementia care and supervision. Section II of the Facility Assessment contained only general statements that staffing was based on resident acuity and an hours-per-patient-day basis, and that staff assignments were designated individually. The assessment did not specify the actual staffing resources needed to meet resident needs, including the number and ratio of direct care staff, licensed nurses, management personnel, or ancillary staff for the facility’s census and acuity. The Sufficiency Analysis categories were documented only as "Evaluated" for multiple domains, including cognitive impairment/dementia, wandering and elopement, and behavioral health needs, without measurable staffing determinations such as minimum nursing staff per shift, CNA-to-resident ratios, licensed nurse-to-resident ratios, Memory Care Unit staffing needs, staffing adjustments based on acuity or census changes, or documentation showing how staffing sufficiency was analyzed and determined. The Administrator stated the assessment had been created, updated, and revised by corporate staff off-site and acknowledged it was not sufficiently detailed or specific to identify the building’s staffing needs.
Facility Assessment Lacked Unit-Specific Staffing Needs
Penalty
Summary
The facility failed to ensure that its facility assessment included specific staffing needs for each resident unit for a census of 72 residents. Review of the facility assessment on 5/20/26 showed a staffing plan stating that direct care staff would include 3 licensed nurses and 7 nurse aides on day shift, 3 licensed nurses and 7 nurse aides on evening shift, and 2 licensed nurses and 4 nurse aides on night shift, with staffing intended to fluctuate based on acuity and staff competency. Further review found that the assessment did not identify staffing needs by resident unit. During an interview on 5/21/26 at approximately 10:23 a.m., Staff F, the Director of Human Resources, confirmed that the facility assessment did not break down staffing for each resident unit.
Facility Assessment Missing Resident Acuity and Staffing Details
Penalty
Summary
The facility failed to ensure its Facility Assessment was reviewed and updated as necessary, and at least annually, to include the resident population, diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population, and other pertinent information for 1 of 1 facility. Record review of the Facility Assessment dated [DATE] showed that the Resident Acuity section did not outline the acuity of the resident population, and the Special Treatments and Conditions section did not include information concerning the resident population. The assessment also did not identify the number of nurse aides needed for the day, evening, and night shifts in the Staff Planning section under Facility Resources Needed to Provide Competent Support and Care for the Resident Population Every Day and During Emergencies. During interview, the Administrator stated he must have overlooked adding the resident acuity information and the number of nurse aides needed to provide care. He stated the Facility Assessment was intended to summarize the types of residents cared for and provide a base for how many staff were needed for different levels of acuity, and that it was a guide for staffing nurses and CNAs on each shift.
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