Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pemiscot County Memorial Hospital during CMS and state inspections, most recent first.
The facility did not maintain a surety bond at the required level to secure residents' personal funds. The policy did not address the need for a bond one and one-half times the average monthly balance of residents' funds. The approved bond was $35,000.00, while the required amount was at least $46,500.00. The Revenue Cycle Director was unaware of this requirement, and the Administrator acknowledged the expectation for compliance.
The facility failed to maintain 24-hour licensed nursing coverage, affecting all residents. The policy required sufficient nursing staff to meet residents' needs, but the Payroll Based Journal (PBJ) Staffing Report showed inadequate coverage for an entire quarter. The Chief Nurse Officer and Administrator were informed of the issue in November 2024, with staff turnover contributing to the deficiency.
The facility failed to provide RN coverage for eight consecutive hours per day, seven days a week, as required by policy. The deficiency was identified through record reviews and interviews, revealing no RN coverage for 90 out of 92 days in the fourth quarter of 2024. The issue was attributed to staff turnover, and the facility's leadership was unaware of the extent of the coverage gaps until November 2024.
The facility failed to obtain physician's orders for code status for several residents, impacting their rights to request or refuse treatment. Despite having forms indicating Full Code or DNR status, these were not signed or dated by the physician or resident. Interviews with staff confirmed the absence of required orders, highlighting a lapse in following state and federal regulations.
The facility failed to issue the required SNF ABN and NOMNC forms to residents and their legal representatives, as mandated by regulations. Specifically, the facility did not provide these notices at least two calendar days before the end of skilled Medicare services for three residents. The Chief Nursing Officer confirmed that the staff was unaware of these forms or the related regulations, leading to the oversight.
The facility failed to maintain a safe, clean, and homelike environment, with observations of stained ceiling tiles, unswept and unmopped floors, and untidy resident rooms. Residents reported longstanding issues with leaks and inadequate housekeeping services. The administration acknowledged dissatisfaction with the contracted housekeeping vendor and was seeking a replacement.
A facility failed to accurately code the MDS for a resident, marking an antidepressant as an antipsychotic. The resident, diagnosed with dementia and other conditions, was prescribed Remeron for visual hallucinations, but no antipsychotic was ordered. The MDS Coordinator mistakenly identified Remeron as an antipsychotic, leading to the error.
The facility failed to follow physician orders for blood glucose monitoring times for two residents, leading to a deficiency in care. A resident with diabetes had their blood glucose checked after meals instead of before, and the required insulin was not administered as ordered. The Chief Nursing Officer confirmed that blood glucose should be checked before meals, and insulin should be administered 15-30 minutes prior, highlighting a systemic issue with adherence to physician orders.
A resident at risk for pressure ulcers was left in a Geri chair without a pressure-reducing device for extended periods, contrary to their care plan and physician's orders. This led to the development and progression of a pressure ulcer from Stage 2 to Stage 3. The resident, with severe cognitive impairment and multiple diagnoses, required substantial assistance for transfers. Facility staff, including the DON and CNO, were unaware of the prolonged chair use, and the physician was not informed of the situation.
A resident with severe cognitive impairment and requiring substantial assistance was transferred without a gait belt, contrary to facility policy. An LPN and CNA conducted the transfer by holding the resident under the arms and pulling on the pants, which was not compliant with safe transfer guidelines. Staff interviews revealed the LPN forgot to apply the gait belt, and the CNA acknowledged the oversight.
The facility failed to ensure an appropriate diagnosis for a psychotropic medication for a resident and did not monitor the drug regimen or follow up on a GDR recommendation for another resident. One resident was prescribed Haldol for insomnia without an appropriate diagnosis, while another had no documented rationale or physician response for GDR recommendations on multiple medications.
The facility failed to maintain and close dumpsters properly, leaving trash exposed and lids open, with furniture obstructing closure. Staff interviews confirmed expectations for proper closure, but no policy was provided.
The facility failed to implement Enhanced Barrier Precautions during wound care for a resident, as an LPN did not wear an isolation gown. Additionally, proper glove changing and hand hygiene practices were not followed during blood glucose monitoring for another resident. The facility also lacked a Legionella risk management process and did not have a policy for infection control in laundry services.
The facility failed to provide the required twelve hours of annual in-service training for two CNAs, as there was no documentation of attendance or time durations for the sessions. The facility lacked a policy for nurse aide in-service training, and the Facility Assessment did not address the mandatory training requirements, including Dementia Care and Resident Abuse Prevention. Interviews with the DON and CNO confirmed the necessity of these trainings.
The facility failed to post daily nurse staffing information in a prominent location accessible to residents and visitors for four days. The staffing information was incorrectly placed by the time clock on the hospital side, contrary to the facility's policy. Interviews with the DON and CNO revealed a lack of awareness about the requirement to post the information in the nursing home area.
A resident dependent on a gastrostomy tube for nutrition and hydration experienced severe weight loss due to the facility's failure to administer prescribed tube feedings and water flushes. Numerous missed opportunities for care were documented, and the resident's condition was not reported to the physician in a timely manner. Staff interviews revealed issues with scheduling and documentation, contributing to the deficiency.
The facility failed to follow physician orders for three residents, resulting in missed medication doses and incomplete lab tests. A resident with a UTI and sepsis had multiple missed antibiotic doses, while another resident with seizures missed several doses of Keppra. Interviews revealed a lack of documentation and awareness among staff, with the DON not auditing charts effectively.
The facility failed to provide sufficient nursing staff, resulting in missed administration of tube feedings, medications, and wound treatments for a resident. The absence of licensed nurse coverage on specific shifts led to incomplete care and documentation, as revealed by interviews with the DON and CNO. The facility relied on hospital staff to cover shifts, lacking a policy for staffing licensed nurses.
The facility did not ensure an RN was on duty for eight consecutive hours daily, as required. Review of schedules and assignment sheets showed no RN coverage on specific dates, despite the facility's assessment tool indicating a need for two RNs. The CNO believed hospital staff were part of the LTC staff, leading to inconsistent RN scheduling.
A resident with severe cognitive impairment and multiple health conditions, including paraplegia, experienced inadequate pressure ulcer care at a facility. The facility failed to consistently perform and document wound assessments and treatments, with numerous missed opportunities for care. Staff interviews revealed lapses in following the facility's wound management policy, leading to insufficient monitoring and documentation of the resident's pressure ulcer.
A resident with an indwelling urinary catheter experienced improper catheter care and documentation deficiencies. Observations showed the catheter bag was often positioned incorrectly, and there were numerous missed opportunities for documenting catheter care. Despite staff awareness and reporting to the DON, the issues persisted.
Failure to Maintain Adequate Surety Bond for Residents' Personal Funds
Penalty
Summary
The facility failed to maintain a surety bond for the security of residents' personal funds at the required level. The facility's policy, titled 'Notice of Rights and Rules' and revised in May 2019, did not address the requirement for a surety bond to be at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months. The facility's approved bond amount was $35,000.00, while the average monthly balance of the residents' personal funds was $30,696.22. This average, when rounded to the nearest thousand, equaled $31,000.00, requiring a bond amount of at least $46,500.00. During interviews, the Revenue Cycle Director was unaware of the requirement for the surety bond to be one and one-half times greater than the average balance, and the Administrator acknowledged the expectation for the bond to meet this requirement.
Insufficient Licensed Nursing Coverage
Penalty
Summary
The facility failed to ensure licensed nursing coverage for 24 hours a day, which was necessary to adequately provide resident care and meet resident needs. This deficiency had the potential to affect all residents residing at the facility, which had a census of 18. The facility's policy, revised in May 2019, required sufficient nursing staff with appropriate competencies and skills to provide nursing and related services to meet residents' needs safely. However, the facility's Payroll Based Journal (PBJ) Staffing Report for Quarter 4, from July 1, 2024, to September 30, 2024, showed insufficient licensed nursing coverage for every day of the quarter. During interviews, the Chief Nurse Officer (CNO) and the Administrator acknowledged the staffing issues. The CNO was informed of the concern in November 2024 when the facility was cited, but was unaware of the extent of the insufficient coverage throughout the quarter. The Administrator also became aware of the staffing concern at the same time. The report indicates that there was significant staff turnover, which contributed to the deficiency in maintaining adequate licensed nursing coverage.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews, revealing that there was no RN coverage for 90 out of 92 days during the fourth quarter of 2024. The facility's policy, revised in May 2019, mandates sufficient nursing staff to meet residents' needs and requires the use of an RN for at least eight hours a day, seven days a week, unless waived. However, the Payroll Based Journal (PBJ) Staffing Report showed a lack of RN coverage from July 1, 2024, to September 30, 2024. Interviews with the Chief Nurse Officer (CNO) and the Administrator indicated that the issue of RN coverage was brought to their attention in November 2024. The CNO was unaware of the extent of the RN coverage gaps during the submitted quarter, attributing the deficiency to significant staff turnover. The Administrator confirmed that a designated Director of Nursing (DON) and a weekend RN were hired to address the staffing requirements, but these actions were taken after the deficiency period.
Failure to Obtain Physician's Order for Code Status
Penalty
Summary
The facility failed to obtain a physician's order for code status for several residents, which is a critical aspect of honoring residents' rights to request, refuse, or discontinue treatment. Specifically, the facility did not have signed or dated code status forms for three residents within the sample and five residents outside the sample. These forms, which indicate whether a resident is Full Code or Do Not Resuscitate (DNR), were either missing or incomplete, lacking necessary signatures from both the physician and the resident or their representative. This deficiency was identified through interviews and record reviews, revealing that the facility's policy on Do Not Resuscitate Orders was not being followed as required by state and federal regulations. The residents involved had various medical conditions, including diabetes, heart disease, dementia, and mental health disorders, which necessitate clear directives regarding their code status. Despite the presence of green and red forms in the residents' charts indicating Full Code and DNR status, respectively, these forms were not properly executed. Interviews with facility staff, including an LPN, the Chief Nursing Officer, and the Director of Nursing, confirmed that there should be a physician's order for each resident's code status, which was not present in these cases. This oversight in documentation and adherence to policy could potentially impact the care and treatment decisions made for these residents in emergency situations.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to issue the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) forms to residents and their legal representatives, as mandated by regulations. Specifically, the facility did not provide these notices at least two calendar days before the end of skilled Medicare services for three residents. This deficiency was identified through interviews and record reviews, revealing that the facility staff was unaware of the requirement to complete these forms. For Resident #9, there was no documentation indicating that the SNF ABN or NOMNC was provided before the end of skilled Medicare services, and the resident remained in the facility. Similarly, Resident #20 was discharged home without receiving the NOMNC, and Resident #69, who also remained in the facility, did not receive the SNF ABN or NOMNC. The Chief Nursing Officer confirmed during an interview that the staff was not aware of these forms or the related regulations, leading to the oversight.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment, as evidenced by multiple observations of unsanitary and unsafe conditions. Ceiling tiles with large brown stains were noted in several areas, indicating potential water damage or leaks. Residents reported that these stains had been present for an extended period, and in some cases, were due to rain seeping in through windows. Additionally, electrical devices were improperly plugged into power adapters, and dirty towels were left on window sills, further contributing to the unsanitary conditions. Housekeeping services were inadequate, with observations of unswept and unmopped floors in resident hallways and rooms. The facility's contracted housekeeping staff was reportedly short-staffed, and there was no daily checklist to ensure cleanliness standards were met. Interviews with staff revealed that housekeeping duties were inconsistently performed, with some areas being neglected due to staff being redirected to other parts of the building. The lack of a maintenance log for repairs and environmental concerns further exacerbated the issue, as staff relied on an online system to report problems, which may not have been addressed promptly. Additional observations included untidy resident rooms with trash on the floor, unmade beds, and foul odors. In one instance, a family member was observed cleaning a room in preparation for a new resident's admission, highlighting the inadequacy of housekeeping services. The facility's administration acknowledged dissatisfaction with the contracted housekeeping services and was in the process of seeking a new vendor. However, the current state of the facility posed a potential risk to the health and safety of all residents due to the unsanitary and unsafe environment.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, which is a federally mandated assessment instrument. The deficiency was identified through observation, interview, and record review. The facility's policy on the Resident Assessment Instrument (RAI) requires comprehensive and accurate documentation to ensure proper care planning. However, the MDS for one resident was incorrectly coded, indicating the resident received a scheduled antipsychotic medication, which was not the case. The resident in question had diagnoses of dementia, hypertension, visual hallucinations, and insomnia. The resident's Physician Order Sheet did not include any orders for antipsychotic medications but did include an order for Remeron, an antidepressant, for visual hallucinations. During an interview, the MDS Coordinator admitted to mistakenly marking Remeron as an antipsychotic on the MDS, leading to the inaccurate assessment. This error highlights a lapse in the facility's adherence to its own policy for accurate MDS documentation.
Failure to Follow Blood Glucose Monitoring Orders
Penalty
Summary
The facility failed to adhere to physician orders for blood glucose monitoring times for two residents, leading to a deficiency in the quality of care provided. Resident #2, who was admitted with diagnoses including type 2 diabetes mellitus, hypertension, heart disease, and heart failure, had an order for blood glucose monitoring before meals and at bedtime. However, on the observed date, the resident's blood glucose was checked after lunch, and the required sliding scale insulin was not administered as per the physician's order. LPN E incorrectly stated that the resident required a different dose and delayed the administration of insulin. Similarly, Resident #7, who was admitted with hypertension and diabetes mellitus, also had an order for blood glucose monitoring before meals and at bedtime. The resident's blood glucose was checked after lunch, contrary to the physician's order. The Chief Nursing Officer confirmed that blood glucose should not be obtained directly after a meal and that sliding scale insulin should be administered 15-30 minutes before a meal. LPN E admitted that blood sugars were checked at specific times, but the sliding scale dose was usually given right after the blood sugar was taken, indicating a systemic issue with following physician orders for blood glucose monitoring and insulin administration.
Failure to Transfer Resident Leads to Pressure Ulcer Development
Penalty
Summary
The facility staff failed to appropriately transfer a resident, identified as at risk for pressure ulcers, from a Geri chair to a bed during sleep, leading to the development of a facility-acquired pressure ulcer. The resident, who was severely cognitively impaired and dependent on staff for various activities, was observed sitting in a Geri chair without a pressure-reducing device for extended periods over several days. Despite having an order to be in bed while sleeping, the resident was left in the chair, which contributed to the development of a Stage 2 pressure ulcer that progressed to Stage 3. The resident's medical history included Alzheimer's disease, anxiety disorder, insomnia, and vascular dementia, with impairments in both lower extremities. The resident was frequently incontinent and required substantial assistance for transfers. The care plan indicated the resident was at risk for pressure ulcers, with interventions to reposition and provide incontinence care. However, observations showed the resident remained in the Geri chair for long periods, even while asleep, contrary to the care plan and physician's orders. Interviews with facility staff, including the Director of Nursing and Chief Nursing Officer, revealed a lack of awareness and adherence to the resident's care plan. The physician was also unaware that the resident was kept in the chair for extended periods, which was detrimental to the resident's wound. The failure to transfer the resident to a bed during sleep and the lack of a pressure-reducing device in the Geri chair were significant factors in the development and progression of the pressure ulcer.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to provide a safe transfer for a resident, identified as Resident #69, who was severely cognitively impaired and required substantial to maximal assistance for transfers. The resident's care plan indicated the need for two staff members to assist with transfers and highlighted the resident's risk for falls. During an observation, it was noted that the resident was transferred from a Geri chair to a toilet without the use of a gait belt, contrary to the facility's policy. The transfer was conducted by an LPN and a CNA who held the resident under the arms and pulled on the top of the pants, which was not in compliance with the established guidelines for safe transfers. Interviews with the staff involved revealed that the LPN forgot to apply the gait belt before the transfer, and the CNA acknowledged that a gait belt should have been used. The CNO mentioned that the resident was probably a Hoyer lift transfer, but this method could not be used for toileting. The failure to use a gait belt during the transfer process was a deviation from the facility's policy and posed a potential risk to the resident's safety.
Failure to Ensure Appropriate Diagnosis and Monitor Drug Regimen
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for the use of a psychotropic medication for one resident and did not monitor the drug regimen or follow up on a gradual dose reduction (GDR) recommendation for another resident. Resident #9 had diagnoses including type 2 diabetes mellitus, bipolar disorder, depression, and anxiety, and was prescribed trazodone, Remeron, and melatonin. A GDR was recommended for these medications, but there was no documentation of a rationale or physician response, and the facility did not follow up with the physician for a rationale. Resident #69, who was admitted with diagnoses of Alzheimer's disease, anxiety disorder, insomnia, and vascular dementia, was prescribed Haldol for insomnia. The facility did not provide an appropriate diagnosis for the use of Haldol, and the Chief Nursing Officer acknowledged that insomnia was not a suitable diagnosis for this medication. The physician also recognized that insomnia was not a good diagnosis for Haldol, although the resident had vascular dementia with some psychosis.
Improper Disposal and Maintenance of Dumpsters
Penalty
Summary
The facility failed to ensure that the dumpsters were properly closed and maintained to prevent pest entry and contain garbage. Observations over several days revealed that the lids of dumpsters one, two, and three were left open, with various trash bags and debris exposed. Dumpster two was obstructed by furniture and shelving, preventing its closure, while a desk chair was consistently found against dumpster three. Additionally, a large opened bag of trash was repeatedly observed on the ground beside dumpster three. Interviews with facility staff, including the Maintenance Director, Housekeeping Supervisor, and Administrator, confirmed that the expectation was for staff to close the dumpster lids after discarding trash. They also stated that there should be no trash or debris on the ground around the dumpsters. Despite these expectations, the facility did not provide a policy regarding the proper maintenance and closure of dumpsters, contributing to the observed deficiencies.
Infection Control Deficiencies in Wound Care, Blood Glucose Monitoring, and Legionella Management
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident, as observed when an LPN did not wear an isolation gown while performing wound care. The LPN was unaware of the need for a gown until after the procedure, and the facility had not educated staff on EBP. The CNO confirmed that the facility had not practiced EBP, and a CNA mentioned that staff should wear gowns and gloves when caring for residents with wounds. Additionally, the facility did not adhere to proper glove changing and hand hygiene practices during point-of-care blood glucose monitoring for another resident. An LPN failed to perform hand hygiene before putting on gloves, did not change gloves between tasks, and did not perform hand hygiene after removing gloves. The LPN acknowledged the need for hand hygiene and glove changes, and the IP and CNO confirmed the correct procedures that should have been followed. The facility also lacked an infection control program and risk management process specific to Legionella disease. The Maintenance Supervisor and IP were unaware of measures to prevent Legionella growth, and the facility had pulled the Legionella policy, deeming it inapplicable. Furthermore, the facility did not have a policy for infection control practices in laundry services, and the IP and CNO were unaware of proper procedures for handling dirty and clean laundry.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to conduct the required twelve hours of annual in-service training for two Certified Nurse Assistants (CNAs), identified as CNA C and CNA D, out of the two sampled. The facility's census was 18 residents. The facility did not have a policy in place for nurse aide in-service training. The Facility Assessment, revised on 02/04/25, did not address the mandatory 12-hour in-service training for nurse aides, which should include Dementia Care and Resident Abuse Prevention training. CNA C, hired on 12/09/14, attended a total of nine in-services from December 2023 to November 2024, but there was no documentation of individual times for each in-service or a total time for the annual in-service trainings. CNA D, hired on 11/11/21, had no documentation of in-service attendance from November 2023 to October 2024. Interviews with the Director of Nursing (DON) and the Chief Nurse Officer (CNO) confirmed that CNAs are required to have 12 hours of in-services annually, covering topics such as abuse, neglect, and dementia management, with documented time durations for each session.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to post the required daily nurse staffing information in a prominent location readily accessible to residents and visitors for four consecutive days. The facility's policy, revised in November 2019, mandates that staffing information be made available in a readable format to residents and visitors at any given time, and that it should be posted daily at the beginning of each shift. However, observations on four different days revealed that the daily nurse staffing information was posted by the time clock located on the hospital side of the building, rather than in the nursing home facility area where it would be accessible to residents and visitors. Interviews with the Director of Nursing (DON) and the Chief Nurse Officer (CNO) confirmed the oversight. The DON acknowledged that the staffing sheet was posted on the hospital side and should have been placed inside the nursing home facility area. The CNO explained that the staffing sheet was placed by the time clock to ensure staff filled out their time worked, but was unaware that it needed to be posted in a prominent area on the nursing home side. This failure to comply with the facility's policy resulted in the deficiency noted by the surveyors.
Failure to Administer Tube Feeding and Water Flushes
Penalty
Summary
The facility failed to administer nutrition and water flushes for a resident who was dependent on a gastrostomy tube for nutrition and hydration. This failure resulted in a severe weight loss for the resident, which was not assessed or reported to the physician in a timely manner. The resident experienced a 9.6% weight loss in 30 days, a 9% weight loss in 90 days, and a 13.3% weight loss in 180 days. The facility's policy required that significant weight changes be reported to the physician, but this was not done until much later. The resident's Medication Administration Record (MAR) showed numerous missed opportunities for administering both the prescribed tube feeding and water flushes. Specifically, there were 32 missed feedings and 36 missed water flushes from 10/04/24 to 10/19/24, and additional missed opportunities were documented in the following weeks. The facility's Director of Nursing (DON) and other staff members were aware of the documentation issues but did not take effective action to ensure that the resident received the necessary care. Interviews with staff revealed that there was a lack of licensed nursing staff scheduled on weekends, and the facility relied on hospital staff to provide care when needed. However, there was no proper documentation or communication between the hospital and facility staff regarding the care provided. The Chief Nursing Officer (CNO) and the Administrator were unaware of the extent of the missed feedings and the resident's weight loss until it was too late. The physician was not informed of the resident's condition, and the care plan was not updated to address the significant weight loss.
Failure to Follow Physician Orders and Document Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for three residents, leading to missed medication administrations and incomplete lab tests. Resident #1 was admitted to the hospital with a urinary tract infection (UTI) and sepsis, and upon return, had orders for Bactrim and amoxicillin. However, there were multiple missed doses of these antibiotics as documented in the Medication Administration Record (MAR). Additionally, a new order for amoxicillin was not fully administered, resulting in further missed doses. The resident was later sent to the emergency room for evaluation due to blood in the urine and pain, and a new antibiotic was prescribed. Resident #2, who was hospitalized for a UTI, had an order for Bactrim DS, but the MAR showed several missed doses. Similarly, Resident #3, diagnosed with seizures, had an order for Keppra, but there were numerous missed doses documented in the MAR. Furthermore, there was no documentation of a completed Keppra level test, as the order was not entered into the system, and the lab confirmed that no test had been conducted. Interviews with facility staff, including the Chief Nursing Officer (CNO), Licensed Practical Nurse (LPN), and Certified Medication Technician (CMT), revealed a lack of documentation and awareness of the missed medications. The Director of Nursing (DON) was expected to audit the charts, but she did not consider it her responsibility to ensure orders were completed. The facility lacked a system to verify that orders were followed, relying solely on the DON's audits, which were not effectively conducted.
Insufficient Nursing Staff and Missed Care Documentation
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide necessary care and services to residents, as evidenced by the absence of licensed nurse coverage 24 hours a day. The review of nursing schedules and assignment sheets revealed multiple instances where no licensed nursing staff were scheduled or worked during both day and night shifts on specific dates. This lack of staffing led to a failure in administering prescribed tube feedings, medications, and wound treatments for residents, particularly affecting one resident who required specific medical interventions. The medical record of a resident showed several orders for tube feedings, water flushes, and antibiotics, as well as wound care treatments. However, there was no documentation of the administration of these treatments on multiple occasions, indicating that the resident did not receive the necessary care as ordered. The resident had been admitted to the hospital with a urinary tract infection and sepsis, and upon return, continued to have specific medical orders that were not consistently followed. Interviews with the Director of Nursing (DON) and Chief Nursing Officer (CNO) revealed that the facility relied on hospital staff to cover shifts when licensed nurses were not scheduled, particularly on weekends. The DON did not consider it her responsibility to audit resident charts to ensure orders were completed, and the CNO was unaware of the extent of missed documentation. The facility lacked a policy for staffing licensed nurses, contributing to the deficiency in care and documentation.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that the facility did not have an RN scheduled and working for the required hours on specific dates. The facility's Facility Assessment Tool indicated a requirement for two RNs, but the nursing schedules and assignment sheets showed no documentation of an RN working the necessary hours on 10/01/24, 11/10/24, and 11/17/24. During an interview, the Chief Nursing Officer mentioned a misunderstanding, believing that hospital staff were considered part of the long-term care staff, and RNs were not always scheduled, with staff calling for assistance from the hospital supervisor as needed.
Failure in Pressure Ulcer Management and Documentation
Penalty
Summary
The facility failed to provide ongoing skin assessments, perform and document treatments, and monitor the progression of a pressure ulcer for a resident. The resident, who was admitted with severe cognitive impairment and multiple health conditions including paraplegia, had an unstageable pressure ulcer on the coccyx. The facility's policy required initial wound exams and ongoing documentation, but there were significant lapses in following these protocols. The resident's treatment records showed inconsistencies and missed opportunities in wound care. Orders for daily wound care were not consistently followed, with 21 missed treatments in October and four in November. Weekly skin assessments were also not documented consistently, with a gap from July to September. When assessments were conducted, they often lacked necessary details such as wound measurements and descriptions. Interviews with facility staff revealed a lack of adherence to the facility's wound management policy. The charge nurse was responsible for dressing changes and documentation, but this was not consistently done. The Chief Nursing Officer expected weekly assessments and complete documentation, but audits to ensure compliance were not mentioned. The deficiency highlights a failure in the facility's processes to ensure proper wound care and documentation for the resident.
Improper Catheter Care and Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper positioning and placement of an indwelling urinary catheter and drainage bags for a resident, leading to potential health risks. Observations revealed that the catheter bag was improperly positioned, either hanging from the bed frame with tubing touching the floor or placed in the resident's lap while in a wheelchair. During a transfer, the catheter bag was held above the resident's bladder, contrary to the facility's policy that requires the catheter to be below the bladder level. Interviews with CNAs indicated uncertainty about proper catheter handling during transfers. Additionally, there was a significant lack of documentation regarding catheter care. The Treatment Administration Records showed numerous missed opportunities for documenting catheter care across two months. Despite being aware of the documentation issues, the facility's staff, including LPNs and a CMT, reported the problem to the DON, but no improvements were noted. The Chief Nursing Officer acknowledged the expectation for staff to provide and document catheter care as ordered, but the documentation was not consistently completed.
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Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Hayti
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southgate Living Center | 5.2 mi | ★★★★★ | 0 | 0 |
| River Oaks Care Center | 11.1 mi | ★★★★★ | 0 | 0 |
| Portageville Health Care Center | 14.2 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Ridgely Rehab&wellness Ctr | 14.3 mi | ★★★★★ | 0 | 0 |
| Reelfoot Manor Health And Rehab | 17.6 mi | ★★★★★ | 0 | 0 |
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