Bedford Care Center Of Picayune

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect resident medications from misappropriation on one of four medication carts, resulting in missing controlled substances for four residents. The facility’s abuse, neglect, and exploitation policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without the resident’s consent. On a specific date, during the 7:00 PM shift change narcotic count, staff identified that multiple doses of Percocet and Norco (hydrocodone-acetaminophen) were missing from the narcotic box on a single medication cart. Prior to this discovery, the assigned LPN had confirmed that the narcotic count was correct earlier in the day. The events leading to the deficiency included the LPN giving her medication cart narcotic keys to an RN while she left the area to perform a urine specimen collection. The LPN did not complete a narcotic count before or after transferring the keys, which was not in accordance with facility expectations for key control and chain of custody. When the LPN returned, she observed the medication cart in the nurses’ station and unlocked. The RN later confirmed that she had moved the cart into the nurses’ station but denied administering any medications during the time she had possession of the keys. During the subsequent 7:00 PM narcotic count, discrepancies were identified, and a search of the cart and nurses’ station did not locate the missing medications. Record review showed that four residents’ controlled medication logs required corrections to reflect missing tablets. One resident with dementia had an order for oxycodone-acetaminophen 5-325 mg every 12 hours as needed for pain; the narcotic log initially showed a remaining balance of 20 tablets after a documented administration, but was later corrected to 16 tablets to account for four missing tablets. A second resident with COPD had an order for oxycodone-acetaminophen 10-325 mg every eight hours as needed; the log was corrected from a remaining balance of five tablets to four, indicating one missing tablet. A third resident with dysphagia had an order for hydrocodone-acetaminophen 5-325 mg every 24 hours as needed; the log showed two tablets on hand after the resident returned from pass with no administrations documented, and was later corrected to zero, indicating two missing tablets. A fourth resident with type 2 diabetes mellitus with diabetic neuropathy had an order for hydrocodone-acetaminophen 7.5-325 mg every six hours as needed; the log was corrected from a remaining balance of eight tablets to seven, indicating one missing tablet. These discrepancies, combined with the unsecured cart and improper key transfer without counts, led to the determination that resident medications were not protected from misappropriation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect residents from neglect in two primary areas: exposure to a known hot-liquid burn hazard and allowing an impaired nurse to remain responsible for resident care and medication administration. On one occasion, a resident with dementia and a severely impaired BIMS score of 03 sustained a burn to the left hip/thigh area when another resident gave him hot coffee, which was then spilled, causing blisters and a new in-house skin issue measuring 7.06 cm by 7.56 cm. The incident report documented that the resident cried out in pain, and subsequent emergency department documentation confirmed the burn was from a coffee spill at the facility. Despite this event, residents continued to have access to hot coffee in the dining room without supervision, temperature controls, or access restrictions for nearly two weeks. The facility also failed to intervene appropriately when an LPN on the night shift was impaired and unable to safely perform nursing duties. Staff statements and camera footage showed the nurse repeatedly falling asleep standing up, leaning over the med cart with eyes closed, crying loudly, moaning, swaying, stumbling, and nearly falling. CNAs reported that residents were calling for their medications, that the nurse fell asleep at the med cart and on the counter in the nurse’s station, and that she repeatedly went to the bathroom for long periods. The DON was notified by another nurse at 1:30 AM that the impaired nurse could not complete the med pass and kept falling asleep, but the impaired nurse remained in the building and responsible for resident care until approximately 3:00–3:30 AM. There was no designated charge nurse on that shift after the scheduled charge nurse called in sick, and no nurse was assigned to supervise staff, coordinate care, or respond to the unsafe condition. Medication administration records and audit reports showed that multiple medications were either not documented as given or were documented late for residents on the impaired nurse’s unit. For four sampled residents, there was no documentation that scheduled evening and bedtime medications were administered on the night in question, including Donepezil for dementia, Crestor, Latanoprost, Novolog, Trazodone, Gabapentin, Duloxetine, Keppra, Lacosamide, and ordered accuchecks. One cognitively intact resident reported being in the dining room, observing that the nurse appeared impaired and unable to safely administer medications, and stated he did not receive his medications and would have been afraid to take them from her. Another cognitively intact resident reported that his medications and blood sugar check were not done and that a CNA told him something was wrong with the nurse. The facility’s own medication administration audit identified 25 residents with missed medications and 5 residents with late medications on that unit during the relevant time frame, and staff confirmed that another LPN pulled medications for the impaired nurse without observing administration, verifying correct resident, or documenting on the MAR, while the impaired nurse retained responsibility and control of narcotic keys. The Administrator acknowledged awareness that the impaired nurse remained on duty until a replacement arrived and that he was not informed of the coffee burn incident until several days after it occurred. He confirmed that, although leadership discussed modifying the coffee service process after he learned of the burn, he did not verify that any changes were implemented or monitored. When surveyors arrived, they were able to obtain hot coffee directly from a dining room machine that was still operational despite signage indicating it was out of service, and the Administrator acknowledged that residents had continued access to hot coffee and that no system had been in place to ensure the discussed intervention was followed. The State Agency determined that these failures to safeguard residents from a known burn hazard and to remove an impaired nurse from resident care created Immediate Jeopardy and substandard quality of care under F600, beginning when residents remained under the care of the impaired nurse.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created to indicate the staff member who tested the temperature of the coffee and the time.
• Coffee temperature logs will be turned into the Administrator daily.
• Training for all staff will be completed prior to their next scheduled shift.
• No staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse.
• Training will include: accidents and supervision including implementing immediate interventions; abuse and neglect reporting and investigation; hot liquids policy; notification of Administrator and DON of unusual occurrences/high risk events and timely notification; charge nurse delegation and duties including assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse and process if assigned charge nurse calls off; posting DON and Administrator phone numbers on the Facility Assignment Grid; requirement to contact DON and Administrator if charge nurse is impaired; updated Facility Assignment Grid to include designated charge nurse; medication administration documentation.
• All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
• Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
• The Facility Assessment was updated by the Administrator to include a contingency plan for absence of supervisory nursing staff and to identify staffing needs by shift and building.
• The facility's Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
• The Scheduler and the Staff Development Nurse were inserviced by the DON on the new Assignment Grid and charge nurse delegation.
• The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
• An emergency Quality Assessment and Assurance Committee meeting was held to review the Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy and to discuss the incident summary, actions taken, training, and monitoring.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving LPN #1.
• LPN #2 was reported to the agency she works for and is not allowed to work at this facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to immediately report allegations of neglect to the State Agency (SA) for two separate events and to implement timely safeguards after serious incidents. In the first event, a resident sustained a burn injury on the left thigh when hot coffee was spilled on the resident’s hip area on 12/31/25 at approximately 3:40 PM. The incident report documented that another resident had given the resident a cup of coffee, which then spilled and caused blistering to the front left thigh/hip area, with wound measurements recorded as approximately 7.06 cm by 7.56 cm and identified as an in-house acquired skin issue. Despite this injury, there was no documentation indicating that interventions were initiated to prevent recurrence or to safeguard other residents who had access to hot coffee. The DON later confirmed that the resident’s burn occurred when another resident provided hot coffee that spilled onto the resident’s leg, and that nursing staff cleansed the area, measured the wound, applied a dressing, and notified the medical provider. However, the DON stated she was not aware of the coffee burn until she returned to the facility on 1/2/26, and confirmed that no immediate interventions were put in place at that time to protect other residents who drink coffee. The coffee machines were not removed; instead, signs were added on 1/6/26 instructing not to use the machines, while the facility began using coffee carafes. On 1/12/26, surveyors observed that a coffee machine in the dining area remained plugged in, operational, and accessible to residents, with hot coffee obtainable without staff assistance or supervision, and no physical barriers in place despite the posted signage. In the second event, the facility failed to immediately report and adequately address an incident involving an impaired LPN responsible for resident care and medication administration on the night shift beginning 12/29/25. The DON received a call at approximately 1:30 AM on 12/30/25 from another LPN reporting that the nurse on Station 2 was unable to complete the medication pass, kept falling asleep, and appeared impaired. Camera footage reviewed by the DON showed the impaired LPN at the nurse’s station and medication cart for about two hours, swaying, stumbling, appearing under the influence, repeatedly falling asleep at the med cart, and being awakened multiple times by CNAs. Statements from CNAs described the LPN falling asleep standing up, crying loudly, going to the bathroom frequently, being “half out of it,” unable to stay awake to pull or pass medications, and failing to administer medications so that residents repeatedly called for their meds. Medication administration audit reports later showed that 25 residents had medications with no administration time documented and 5 residents had medications documented as administered late. The impaired LPN remained on duty and responsible for resident care until approximately 3:00–3:30 AM, when a replacement nurse arrived, and was later discharged from employment. Another LPN who relieved the impaired nurse reported that she was very drowsy, unable to give report, stumbling, and unable to participate in the narcotic count. The Administrator acknowledged awareness of the incident involving the impaired LPN on the 12/29 PM shift and confirmed that the nurse remained on duty for about eight hours until a replacement arrived. The Administrator also acknowledged awareness of the resident’s coffee burn but stated he did not learn of it until six days after it occurred. He reported that he did not consider either the impaired nurse incident or the coffee burn incident to be neglect and therefore did not report them to the SA as alleged violations, despite the facility’s policy requiring prompt reporting of alleged neglect to local, state, and federal agencies.

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 and started that indicate the staff member who tested the temperature of the coffee, the time and 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.
• Training content includes accidents and supervision including implementing immediate interventions.
• Training content includes abuse and neglect reporting and investigation.
• Training content includes the hot liquids policy.
• Training content includes notification of the Administrator and Director of Nursing (DON) of unusual occurrences, high risk events, and timely notification.
• Training content includes charge nurse delegation and duties to include the 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 designated charge nurse.
• Training content includes 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 by the Administrator 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.
• Summary of incident was discussed with actions taken including training and monitoring.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving LPN #1.
• LPN #2 was reported to the agency that she works for and is not allowed to work at this facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct thorough and timely investigations and to implement safeguards following two separate events involving potential neglect. In the first event, a resident sustained a burn on the left thigh on 12/31/25 at approximately 3:40 PM after another resident gave the resident a cup of hot coffee, which was then spilled, resulting in blistering. Nursing documentation described a new in-house acquired skin issue on the front left trochanter, with a blister measuring 7.06 cm by 7.56 cm. Although staff cleansed the area, measured the wound, applied a dressing, and notified the medical provider, there was no documentation of interventions to prevent recurrence or to safeguard other residents who drink coffee immediately after the incident. The facility did not promptly identify or control the environmental hazard associated with resident access to hot coffee. On 1/12/26 at 7:20 AM, surveyors observed a coffee machine in the dining area that was accessible to residents, labeled out of service but still plugged in and operational. The State Agency was able to obtain hot coffee from the machine without staff assistance or intervention while residents were present in the dining area, and no staff were observed supervising or restricting resident access. No physical barriers were in place to prevent resident use of the machine despite the posted signage. The DON confirmed that no immediate interventions were implemented to safeguard other residents who drink coffee between the time of the burn on 12/31/25 and 1/6/26, and did not describe interviewing residents who drink coffee, reviewing procedures to check coffee temperatures, or assessing environmental risks related to access to hot liquids. In the second event, the facility failed to thoroughly investigate and respond to an impaired nurse who was responsible for resident care and medication administration. On the 12/29/25 7:00 PM–7:00 AM shift, an LPN on Station B appeared impaired, repeatedly fell asleep standing up and at the med cart, cried loudly, and was described by CNAs as half out of it, with legs giving out and requiring a chair placed behind her. Camera footage reviewed by the DON showed the nurse swaying, almost falling, stumbling, staring at the med cart and medication cards for extended periods, and falling asleep at the med cart in the dining room while a resident was present. CNA statements indicated that residents repeatedly called for their medications, that the nurse did not complete the med pass, and that no one received medications for a period, while the nurse remained on duty until approximately 3:00–3:30 AM. 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 time frame. The DON was notified at approximately 1:30 AM by another LPN that the nurse on Station B was unable to complete the med pass and kept falling asleep, but the DON only verbally confirmed with the reporting nurse that residents had received their medications and did not verify this by reviewing Medication Administration Records, Medication Audit Reports, or interviewing residents. The DON did not describe reviewing all events leading up to and following the incident to determine root cause or to prevent recurrence. The Administrator acknowledged awareness of the impaired nurse incident and that the nurse remained on duty until a replacement arrived about eight hours after the start of the shift, but he did not review MARs, Medication Audit Reports, or other documentation to verify whether medications were administered accurately and timely. The facility’s own investigation documents and counseling/discipline report for the impaired LPN noted that the nurse did not complete the med pass and only gave medications to two residents, yet there was no evidence of a comprehensive investigation consistent with the facility’s Abuse Investigation and Reporting policy, which requires thorough review of documentation, medical records, interviews with residents and staff, and review of all events leading up to the alleged incident. The Administrator and DON both confirmed that they did not initiate formal investigations consistent with facility policy for either the coffee burn or the impaired nurse incident. For the coffee burn, the Administrator stated he was not aware of the incident until six days after it occurred and confirmed there were no immediate interventions to safeguard other residents who drink coffee or to assess environmental risks related to access to hot liquids immediately following the incident. For the impaired nurse, the Administrator acknowledged he relied on being told that residents had received their medications and did not independently verify medication administration accuracy or timeliness. These actions and inactions resulted in the facility failing to investigate alleged neglect, failing to prevent further potential neglect, and allowing unsafe conditions to continue for residents with access to hot coffee and for all residents on Station B under the care of the impaired nurse.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created to document the staff member who tested the coffee temperature and the time/date.
• Coffee temperature logs will be turned into the Administrator daily.
• All staff will be trained 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 training topics include: Accidents and Supervision (including implementing immediate interventions); Abuse and Neglect Reporting and Investigation; Hot Liquids Policy; Notification of Administrator and DON of unusual occurrences/high risk events and timely notification; Charge Nurse Delegation and Duties (including assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse and notification process if assigned charge nurse calls off); Medication Administration Documentation.
• DON and Administrator 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.
• Facility Assignment Grid was updated to include assignment for designated charge nurse.
• 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.
• Facility Assessment was updated by the Administrator to include a contingency plan for absence of supervisory nursing staff and to identify staffing needs by shift and building.
• Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
• Scheduler and Staff Development Nurse were inserviced by the DON on the new Assignment Grid and Charge Nurse Delegation.
• 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 was held with interdisciplinary attendance and the Medical Director present via telephone.
• The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made.
• The incident summary was discussed with actions taken including training and monitoring.
• 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 she works for and is not allowed to work at this facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to keep the resident environment free from accident hazards and to provide adequate supervision related to hot liquids, resulting in a resident sustaining a burn from hot coffee. On 12/31/25 at approximately 3:40 PM, a resident with dementia and a severely impaired BIMS score of 03 received hot coffee from another resident in the dining area. The coffee spilled onto the resident’s left thigh/hip area, causing pain and visible blistering. Staff documentation and progress notes identified a new in-house skin issue on the front left trochanter, described as a blister measuring approximately 7.06 cm by 7.56 cm, and the facility’s Medical Director later confirmed this as a second-degree thermal injury from hot coffee. At the time of the incident and in the days following, the facility did not implement environmental controls or supervision to prevent other residents from exposure to the same hot coffee hazard. The facility’s own “Safety of Hot Liquids” policy required hot liquids to be served at safe temperatures, not more than 140°F, with appropriate safety precautions such as staff supervision or assistance and regulation of temperatures for liquids to which residents had direct access. However, review of the facility’s Hot/Cold Holding Temperature Log (coffee logs) showed no coffee temperatures were recorded prior to 1/6/26. Observations on 1/12/26 at 7:20 AM revealed a coffee machine in the dining area that remained plugged in, operational, and accessible to residents, despite being labeled “out of service.” The State Agency was able to obtain hot coffee from this machine without staff assistance or intervention while residents were present and no staff were supervising or restricting access, and there were no physical barriers to prevent resident use. Interviews with facility leadership and staff further demonstrated inaction and lack of timely response to the identified hazard. The DON stated that the incident occurred when one resident provided hot coffee to the cognitively impaired resident, resulting in the burn, and confirmed that she did not become aware of the incident until 1/2/26. She acknowledged that after learning of the burn, no immediate corrective or preventive measures were implemented to reduce the risk of other residents sustaining burns from hot liquids, and that resident access to coffee machines continued without restriction, supervision, or temperature control between 12/31/25 and 1/6/26. The Administrator reported he was not informed of the burn incident until a stand-up meeting on 1/6/26 and confirmed that, even after leadership discussed modifying the coffee service process, he did not verify that any changes were implemented or monitored. A cognitively intact resident reported that residents continued to obtain coffee directly from the machines and that staff did not consistently unplug them, corroborating that residents had ongoing access to hot coffee in violation of the facility’s safety and supervision policies. The facility’s “Safety and Supervision of Residents” policy stated that the environment should be as free from accident hazards as possible, that safety risks and environmental hazards would be identified on an ongoing basis, and that the QAPI/Safety Committee would evaluate hazards and develop strategies to mitigate or remove them. It also required the interdisciplinary team to identify specific accident hazards for individual residents and to implement and communicate targeted interventions, including adequate supervision. Despite these written expectations, the facility did not identify the hot coffee machines as an ongoing environmental hazard after the burn incident, did not promptly analyze or address the risk for other residents, and did not implement or enforce supervision, access restrictions, or temperature regulation for hot coffee until after the State Agency’s on-site observations. Resident #1’s medical record also showed that the burn had been present and under treatment for several days before the family requested an Emergency Department evaluation, where the history documented that the patient had been burned at the nursing home from a coffee spill about a week earlier. This further supports that the burn was recognized and being treated in-house while the underlying environmental hazard—resident access to excessively hot coffee from accessible machines in the dining room—remained unmitigated. The combination of the initial incident, the lack of timely hazard recognition and control, and the continued availability of hot coffee without supervision or temperature monitoring constituted the deficient practice under 42 CFR §483.25(d)(2) related to accidents and hazards.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created to indicate the staff member who tested the temperature of the coffee and the time.
• Coffee temperature logs will be turned into the Administrator daily.
• Training for all staff 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 (Accidents and Supervision including implementing immediate interventions; Abuse and Neglect Reporting and Investigation; Hot Liquids Policy; Notification of Administrator and DON of unusual occurrences/high risk events and timely notification; Charge Nurse Delegation and Duties including assignment of charge nurse; Medication Administration Documentation).
• All residents were evaluated for safety with hot liquids by nursing leadership 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 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.
• 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.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
• An emergency Quality Assessment and Assurance Committee meeting was held to review the Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy and discuss incidents/actions taken including training and monitoring.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving an LPN.
• An LPN was reported to the agency that she works for and is not allowed to work at this facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records and to document medication administration in accordance with its own policy and accepted professional standards. The facility’s policy on administering medications, revised 8/2/22, requires that medications be administered in a safe and timely manner as prescribed, that the resident be observed taking the medication, and that the nurse document on the EMAR when the medication is administered. A review of the Medication Admin Audit Report for Station B for 12/29/25–12/30/25 showed that 25 residents had medications with no administration time documented and 5 residents had medications documented as administered late by at least one hour. These findings indicated that medication administration could not be verified as accurate and timely for multiple residents on the night shift of 12/29/25. During interviews, the DON confirmed that facility policy requires licensed nurses to document all medications administered, held, or not administered on the MAR at the time of administration. She acknowledged that there was an impaired nurse working on 12/29/25 and that she relied on LPN #2’s statement that residents’ medications had been administered, without verifying the MAR documentation at that time. LPN #2 reported that she accessed the medication cart and pulled medications for the impaired nurse but did not administer the medications herself, did not document them on the MARs, and did not accompany or observe the impaired nurse during medication administration. LPN #2 further confirmed that she did not visually verify that the correct medications were administered to the correct residents and did not perform any checks or follow-up verification to ensure medications were given as ordered or documented. Record review for four sampled residents showed specific undocumented medication administrations on the night of 12/29/25. Resident #1, with dementia and a severely impaired BIMS score of 03, had an order for Donepezil 5 mg at bedtime, with no documentation of the 8:30 PM dose. Resident #2, cognitively intact with a BIMS score of 15 and diagnoses including cerebral infarction, hyperlipidemia, glaucoma, diabetes mellitus, and insomnia, had active orders for Crestor, Latanoprost eye drops, Novolog before meals and at bedtime, and Trazodone at bedtime, with no documentation of receiving scheduled 8:00 PM or 9:30 PM medications. Resident #3, cognitively intact with hemiplegia and hemiparesis following cerebral infarction and orders for Accuchecks AC and HS, Gabapentin, Guaifenesin, Keppra, and Lacosamide, had no documentation of receiving any 8:30 PM medications. Resident #4, with senile degeneration of the brain, dementia, and a moderately impaired BIMS score of 9, had orders for Clonidine, Duloxetine, and Gabapentin, with no documentation of receiving any 8:30 PM medications on that date.

Penalty

Inspection fine: $30,775

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a required Significant Change PASRR for one resident after the resident was started on antipsychotic medication. The resident had a prior Level I PASARR completed before admission, was admitted with chronic systolic heart failure, and later was diagnosed with unspecified psychosis not due to a substance or known physiological condition. A Significant Change MDS completed with an ARD of September 19, 2025 documented a BIMS score of 03, indicating severe cognitive impairment, and listed active diagnoses of anxiety disorder, depression, and psychotic disorder other than schizophrenia. Record review showed the resident had been prescribed Vraylar 1.5 mg and later an increased dose of Vraylar 6 mg for psychosis, and psychiatry notes reflected ongoing psychiatric services. Facility interviews confirmed the resident had been receiving psychiatric care, but the Social Services Director stated that no PASARR Level II had been completed because the referral was not submitted and she was unaware that a Level II submission was required. The facility policy required residents with newly evident or possible serious mental disorder, including those receiving a new order for antipsychotic or psychotropic medication when not previously taking such medications prior to admission, to be promptly referred for Level II PASARR review.

Penalty

Inspection fine: $30,775

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive care plan with appropriate interventions for Resident #7 after the resident was diagnosed with a urinary tract infection (UTI). The resident was admitted on 07/31/2025 with diagnoses including polyneuropathy. A urine culture resulted on 12/10/2025 and was positive for greater than 100,000 counts of Klebsiella pneumoniae. A physician's order dated 12/10/2025 directed Cefuroxime Axetil, 1 tablet by mouth two times a day for UTI. Record review showed no comprehensive care plan with interventions was developed to address the UTI diagnosis or to identify the resident as at risk for UTI. During interviews, an LPN confirmed the resident was being treated with antibiotics for UTI, an RN stated care plans were updated when a resident had a new medication or change in condition, and another RN confirmed the positive urine culture, antibiotic treatment for seven days, and the absence of a care plan addressing the UTI diagnosis or risk for UTI. The DON stated the purpose of the care plan was to guide staff on how to care for the resident and that she would expect a care plan to be developed for a resident with a current UTI receiving antibiotic therapy.

Penalty

Inspection fine: $30,775

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store medications in a safe and secure manner for two of four medication carts reviewed. Facility policy required all drugs and biologicals to be stored in a safe, secure, and orderly manner, and stated that carts containing drugs and biologicals must be locked when not in use and not left unattended if open or otherwise potentially available to others. During observation of medication pass in Building One, an LPN left a medication cart unattended and unlocked on the resident hallway while going to the medication room, and the cart remained unattended and unlocked for several minutes. The cart contained medications for multiple residents, including aspirin, vitamins, acetaminophen, eye drops, and prescription blood pressure medications. The LPN confirmed the cart was left unlocked and acknowledged a resident could have accessed it. Later the same day in Building Two, another medication cart was observed left unattended and unlocked on the resident hallway, and an LPN confirmed it was unlocked before locking it after responding to an event involving a resident on the other side of the building.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an advance directive, specifically a durable Power of Attorney (POA), was available and readily retrievable for a resident. Upon review of the resident's electronic health record, it was found that there was no copy of an advance directive or POA in the medical chart, despite the resident's representative having provided a POA to the facility. The Director of Nursing (DON) clarified that the POA was stored on the Administration Side of the electronic health record, which was not accessible to nurses or clinical staff. This oversight meant that the POA was not visible under the Special Instructions section, which is accessible to all staff. Further investigation revealed that the Admission Coordinator, who is responsible for discussing advance directives with residents and their representatives, kept a copy of the POA in a binder located in a separate building that was locked after hours and on weekends. This arrangement made the POA not readily retrievable by facility staff. The resident involved had been admitted with diagnoses including Hemiplegia and Hemiparesis, and the lack of accessible advance directive documentation could potentially affect all residents with a durable POA.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise comprehensive care plan interventions for three residents, leading to deficiencies in care. For one resident with Chronic Obstructive Pulmonary Disease (COPD), the care plan contained conflicting instructions regarding oxygen therapy. The care plan indicated continuous oxygen use, while a physician's order required titration to maintain oxygen saturation above 92%. This discrepancy was confirmed by registered nurses during interviews, who acknowledged the oversight in reconciling care plans with physician orders. Another resident with cancer experienced a deficiency in pain management care planning. The care plan included an intervention for a Fentanyl patch but failed to address a physician's order for morphine sulfate. Interviews with nursing staff revealed that the care plan had not been updated to reflect the increased dosage of the Fentanyl patch and the addition of morphine sulfate, despite daily reviews of new physician orders. A third resident with a history of Post Traumatic Stress Disorder (PTSD) had a care plan that lacked interventions to identify triggers and prevent re-traumatization. The care plan did not include necessary information about the resident's PTSD diagnosis and potential triggers. Interviews with nursing and social services staff confirmed the absence of these critical interventions, which are essential for providing trauma-informed care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its food safety policy by not discarding expired foods and not labeling opened foods with a use-by date. During an initial tour of the kitchen, a Dietary Manager observed an opened gallon of buttermilk in the Cook's Refrigerator that was past its manufacturer's expiration date. Additionally, in the walk-in refrigerator, there were clear containers of olives and an opened container of sour cream, both lacking an opened or use-by date. The Dietary Managers confirmed these findings and acknowledged that it was everyone's responsibility to ensure proper labeling and discarding of expired foods, but ultimately, it was their responsibility to oversee these tasks.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly store and maintain respiratory equipment for a resident receiving oxygen therapy. During an observation, it was noted that the oxygen nasal cannula tubing was wrapped around the concentrator and not stored in a designated container. Additionally, the nebulizer mask was hanging down the side of the bedside table without being stored in a bag. The disposable humidifier water bottle attached to the oxygen concentrator was dated 12/21/23, indicating it had not been changed in a timely manner, as it was expected to be changed weekly. The resident involved had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and had physician's orders for oxygen therapy and nebulizer treatments. Interviews with facility staff revealed a lack of adherence to proper storage and maintenance protocols for respiratory equipment. An LPN stated that the resident was not currently using oxygen as it was ordered on an as-needed basis and admitted to not checking the oxygen water humidifier bottle or tubing storage, as it was the responsibility of the night shift staff. A subsequent interview with an RN confirmed the improper storage of the nasal cannula and nebulizer mask and acknowledged the outdated humidifier bottle. The Director of Nursing expressed expectations for proper storage and timely replacement of oxygen equipment, which were not met in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy required identifying triggers and implementing resident-specific interventions to minimize re-traumatization. However, the facility did not evaluate the resident to identify such triggers or develop a care plan with specific interventions. The resident, admitted with a diagnosis of PTSD, had a history of physical and mental abuse and a previous suicide attempt, yet there was no documentation of an assessment to identify potential triggers. Interviews with facility staff, including a Certified Nurse Aide (CNA), a Licensed Practical Nurse (LPN), the Social Services Director (SSD), the Director of Nursing (DON), and the facility's Administrator, revealed a lack of awareness and documentation regarding the resident's triggers. The SSD acknowledged that although a trauma screen was completed, no further attempts were made to gather information from the Veteran's Administration hospital where the resident was previously treated. The facility's failure to identify and document triggers for the resident with PTSD resulted in a lack of trauma-informed care, as confirmed by the staff interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to discard expired stock medications in one of the five medication storage areas reviewed, specifically at the nurses' station in Building 1. During an observation on May 20, 2024, expired medications were found, including Magnesium 750 mg with an expiration date of December 2023, and Folic Acid 1 mg and Aspirin 325 mg, both with expiration dates of January 2024. The facility's policy, revised on July 17, 2023, mandates that all medications be stored according to the manufacturer's recommendations and that unused medications be routinely inspected by the consultant pharmacist for expiration or defects. Interviews with staff revealed that it was the responsibility of the cart nurses to discard expired medications from the medication carts and storage areas. A registered nurse confirmed the presence of expired medications and acknowledged that they should not have been in the stock medication area. The Director of Nursing also confirmed this responsibility and expressed an expectation for nurses to regularly check for expired medications. The report highlights that using expired medications could pose a potential hazard due to changes in their efficacy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide hand hygiene for residents prior to meals in one of the four dining rooms observed, specifically Dining Room C. The facility's policy on hand hygiene, revised on August 2, 2022, emphasizes the importance of hand hygiene as a primary means to prevent the spread of infections. The policy states that residents should be encouraged to practice hand hygiene, particularly before and after eating or handling food. However, during an observation on May 20, 2024, at 10:51 AM, it was noted that the facility staff did not offer assistance to residents for washing or sanitizing their hands in Dining Room C. This observation was made in the presence of four CNAs and one LPN. Further observations on the same day at 11:44 AM revealed that three residents were assisted to the dining room table by therapy staff without being offered assistance with hand hygiene before the meal. The Director of Nursing, present during the observation, acknowledged that CNAs were responsible for assisting residents with hand hygiene before meals. Interviews with CNA #1 and a Physical Therapy Assistant confirmed that staff did not offer hand hygiene assistance to residents before lunch, and therapy staff did not assist residents in washing their hands before entering the dining room.