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:
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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