Brandon Community Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brandon, Mississippi.
- Location
- 355 Crossgate Blvd, Brandon, Mississippi 39042
- CMS Provider Number
- 255106
- Inspections on file
- 32
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Brandon Community Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, unsteadiness on feet, and documented memory problems fell and sustained multiple head and facial injuries after a housekeeper mopped the resident’s room floor without placing wet floor signage. The housekeeper, working on the unit for the first time, assumed the resident was bedridden and would not get up, and reported that no wet floor signs were available. Shortly after the room was mopped, staff heard the resident crying and found the resident lying face down on a wet floor in a pool of blood, with no caution sign present. Clinical documentation and hospital records noted lacerations to the head and face, periorbital discoloration, an acute orbital blowout fracture, and suspected concussion. Interviews with the DON, CNA, LPN, and administrator confirmed that the floor was wet from recent mopping, no wet floor sign had been placed, and staff had not identified the wet floor as a hazard before the incident.
A resident with a history of mental health diagnoses began exhibiting new exit-seeking behaviors, such as packing belongings and waiting at the front door, but staff did not update her care plan or implement additional supervision. The resident exited the facility unnoticed and was found in a staff member's car in the parking lot after about fifteen minutes. No incident report was completed, and no missing resident protocol was initiated, despite the facility's policy requiring intervention for such behaviors.
A resident with a history of mental health disorders exited the facility unsupervised and was found in a staff member's car in the parking lot after being missing for about fifteen minutes. The event was not documented as an elopement, no incident report was completed, and required notifications to authorities were not made, despite facility policy and staff awareness of the incident.
A resident with multiple psychiatric diagnoses exited the facility unsupervised and was found in a staff member's car in the parking lot. Staff failed to initiate missing resident procedures, did not complete an incident report, and did not conduct a thorough investigation or notify the State Agency, despite facility policy requiring immediate action for such incidents.
Two residents did not have comprehensive care plans developed or updated to address significant changes in their conditions. One resident exhibited new wandering and exit-seeking behaviors that were documented by staff but not reflected in the care plan, resulting in an unsupervised elopement. Another resident was admitted with a nephrostomy tube, but the care plan did not include any instructions or interventions for its management, and staff were not provided with formal guidance. Facility policies requiring timely and person-centered care plan updates were not followed.
A resident with a history of mental health conditions and recent wandering and exit-seeking behaviors exited the facility unnoticed and was found unsupervised in a staff member's car in the parking lot. Despite clear behavioral changes, staff did not update the care plan, implement elopement precautions, or follow facility protocols, resulting in a failure to provide adequate supervision and a secure environment.
A resident with a nephrostomy tube did not receive or have documented any dressing changes or tube flushes during their stay. Nursing staff did not perform routine maintenance due to the absence of physician orders or care plan instructions, and the DON and Medical Director confirmed that required care and documentation were not provided, resulting in a failure to meet professional standards.
A resident with diabetes and end stage renal disease did not receive daily skin and foot assessments as required by their care plan. Staff failed to identify or document developing foot wounds, which were first discovered and treated at a dialysis center. Despite notification from the dialysis center, facility staff did not assess or treat the wounds for several days, and the wound care team was not consulted until later.
A resident with end-stage renal disease and severe cognitive impairment developed wounds on the right foot that were identified and treated by dialysis staff, who notified facility staff of the need for follow-up. Despite this, facility staff did not assess or treat the wounds for several days, failed to document the issue, and did not notify the physician or wound care team, resulting in a delay in care and lack of appropriate interventions.
A resident with cognitive impairment and dependence on hemodialysis did not have a pressure dressing removed from a dialysis access site within the time frame specified by the care plan and physician's order. Staff interviews and record reviews confirmed that the care plan was not followed, resulting in the dressing remaining in place longer than directed.
A resident dependent on renal dialysis did not have a pressure dressing removed from their access site within the required timeframe, despite clear physician orders and instructions from the dialysis unit. The dressing remained in place overnight, and the resident, who was visually impaired, was unable to remove it independently. Staff and administration confirmed the failure to follow orders and instructions for timely dressing removal.
Two residents did not have complete or properly implemented care plans: one with an indwelling urinary catheter lacked a care plan addressing catheter care and privacy, resulting in the catheter bag being left uncovered in public areas, while another dependent resident did not consistently receive scheduled showers due to discrepancies between the care plan and staff scheduling. Staff interviews confirmed lack of awareness and communication regarding these care needs.
A resident with multiple urinary diagnoses had an indwelling Foley catheter in place without a documented physician order, contrary to facility policy. Staff, including an LPN and the MDS nurse, were unaware of the need for a catheter order or the presence of the catheter, and the DON and Administrator confirmed the lack of compliance with professional standards of care.
A resident with severe cognitive impairment and multiple medical conditions was observed in a common area with an uncovered urinary catheter bag containing visible urine. Multiple staff, including an LPN and the MDS Nurse, were unaware of the need for a catheter bag cover, resulting in a failure to maintain the resident's privacy and dignity as required by facility policy.
Two residents did not receive necessary hygiene and grooming care as required by facility policy. One resident had facial hair that interfered with eating and was not trimmed despite expressing discomfort, while another dependent resident did not receive scheduled showers for at least two weeks, even though appropriate equipment was available. Staff interviews revealed inconsistencies in care delivery and scheduling.
The facility failed to maintain a safe and sanitary environment, affecting multiple residents. Observations revealed cluttered and dirty rooms, with dried spots on equipment and furniture, and the presence of pests. Interviews with staff highlighted issues with housekeeping and maintenance, contributing to the unsanitary conditions.
A resident with severe cognitive impairment and incontinence was not provided timely care, remaining in wet briefs for over three hours. Facility policy required checks every two hours, but staff failed to adhere to this, with the CNA leaving without making rounds and the subsequent CNA not checking the resident until later. The LPN and DON confirmed the delay and acknowledged the impact of staffing issues on care.
A facility failed to provide care to a resident with a feeding tube according to medical orders. The resident's enteral feeding pump was turned off for over four hours, despite orders to hold feeding for only 30 minutes before meals. The LPN expressed confusion about the orders, and the DON confirmed the feeding should not have been held for so long, potentially affecting the resident's nutritional needs.
The facility experienced staffing shortages on multiple days, leading to inadequate care for residents. Staff interviews and record reviews revealed that CNAs were often overburdened, resulting in delayed care. The Staff Development Director did not use the Facility Assessment Tool for scheduling, relying instead on census numbers. A resident reported long wait times for assistance, and CNAs were sometimes reassigned to non-care duties, further impacting care quality.
The facility failed to ensure a clean and homelike environment, as observed in the rooms of two residents, a shower room, and a hallway. A resident's room was found dirty with trash and dust, while another resident's room had a strong urine odor due to incontinence issues. The shower room had stains on the floor, and the hallway had dusty decorative items and dirty hand sanitizer dispensers. The Housekeeping Supervisor and Administrator acknowledged the issues, citing staffing challenges.
The facility failed to ensure proper food storage and labeling in the walk-in refrigerator and freezer. Unlabeled and undated containers with unknown substances were found, and food was stored on the floor. The Dietary Manager, responsible for these tasks, had been out sick and decided not to return. The facility received a C rating from a recent MSDH inspection.
A resident with severe cognitive impairment and multiple diagnoses refused medications for several days without the attending physician or responsible party being consistently notified, contrary to the facility's policy. The Pharmacy Consultant, Physician, and Nurse Practitioner were unaware of the extent of the refusals, and the facility lacked a system to address the issue.
The facility failed to maintain a clean, homelike environment by not ensuring clean linen was available for two residents. One resident had to sit in a chair due to the lack of clean sheets, while another was found without a fitted sheet on the mattress. Staff interviews revealed that linen was available, but staff were either unaware of its location or used the lack of linen as an excuse not to change beds.
A facility failed to maintain a medication error rate below 5%, resulting in a 12.12% error rate. An LPN administered medications via a PEG tube instead of by mouth as per physician's orders. The DON confirmed the error upon review.
The facility failed to serve food in a manner that was appealing and palatable for two residents. One resident, with Type 2 Diabetes Mellitus and Iron Deficiency Anemia, stated the food tasted like slop. Another resident, with diagnoses including Orthopedic Aftercare and Hypertension, complained the food tasted bad. A lunch tray tested with the Dietician revealed bland vegetables, and the Dietician acknowledged the issue. The second resident ate only 50% of the lunch meal and preferred fresh fruits and vegetables.
The facility failed to ensure that residents who smoked were allowed to exercise their right to smoke during designated times. Two residents reported not receiving scheduled smoking breaks and observed staff idling instead of assisting them. Interviews with staff confirmed the issue, and the Director of Nursing acknowledged the negative impact on residents' feelings.
A resident with severe cognitive impairment and multiple diagnoses reported not receiving scheduled showers, leading to discomfort and complaints. Despite a grievance filed by the resident's daughter and an interdisciplinary team meeting, the issue remained unresolved due to inconsistent care and poor communication among staff.
A resident dependent on staff for ADLs and incontinent care was left soiled for extended periods, especially during the night shift. Despite complaints from the resident and her daughter, staff failed to provide timely care, leading to the resident using a pillowcase to absorb urine. Observations and interviews confirmed the deficiency in care practices.
Failure to Prevent Fall After Room Was Mopped Without Wet Floor Signage
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free as possible from accident hazards and to provide adequate supervision and assistance to prevent accidents, resulting in a resident fall with injury. Facility policies titled “Safety and Supervision of Residents” and “Homelike Environment” state that resident safety, supervision, and a safe environment are priorities. Despite these policies, a housekeeper entered a resident’s room at approximately 10:30 AM, found the resident asleep, and proceeded to clean and mop the floor without placing any wet floor signage. The housekeeper reported believing the resident was bedridden and did not expect the resident to get up unassisted, and also stated that no wet floor signs were available and that it was their first time working on the unit. Progress notes and witness statements document that shortly after the room was mopped, staff heard the resident crying and found her lying face down on the wet floor in a pool of blood, with no wet floor sign in place. The resident sustained multiple injuries, including a 2 cm laceration to the top of the head, a 0.75 cm laceration to the forehead, a 0.25 cm laceration on the bridge of the nose, discoloration and contusions around both eyes, and discoloration to the left knee. A Family Nurse Practitioner documented that the resident was seen on the floor with blood pooled around her head and lacerations to the forehead and nose, with a contusion forming over the left eye. Hospital records further documented facial trauma, an orbital fracture, and suspected concussion, with suturing required for the laceration and imaging confirming an acute orbital blowout fracture of the left orbital floor. Interviews with staff confirmed that the floor was wet from recent mopping and that no caution signage had been placed. The Director of Nursing stated that the resident was last seen around 10:55 AM and was found around 11:00 AM lying face down on the wet floor, confirming that the housekeeper had assumed the resident was not mobile. A CNA reported having assisted the resident with a shower and returning her to her room, where the resident was sitting up watching television prior to the incident, and later found the resident on the wet floor with no sign present. An LPN described entering the room after hearing the resident crying, stumbling on the wet floor, and finding the resident face down with blood on her face and hair. The Licensed Nursing Home Administrator confirmed that the housekeeper mopped the floor without posting a wet floor sign and that staff did not identify the wet floor as a potential hazard prior to the incident. Record review showed the resident had Alzheimer’s disease, unsteadiness on feet, and documented memory problems with some difficulty in new situations, indicating known cognitive and mobility issues at the time of the fall.
Failure to Prevent Resident Elopement Due to Lack of Timely Intervention
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not implementing measures to prevent elopement for a resident who had recently begun exhibiting exit-seeking behaviors. The resident, who had diagnoses including bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, began displaying new behaviors such as packing belongings and waiting at the front door, believing her family was coming to get her. Despite these documented behaviors, staff did not update the resident's care plan or implement additional supervision or wander management interventions prior to the incident. On the day of the incident, the resident exited the facility unnoticed and unsupervised. She was found approximately fifteen minutes later by a CNA, sitting in the passenger seat of the CNA's car in the facility parking lot, which was located near a busy four-lane boulevard. Staff were unaware of the resident's absence until she was brought back inside. There was no incident report completed at the time, and no head count or missing resident protocol was initiated following the event. Interviews with staff confirmed that the resident's care plan had not been updated to reflect her new exit-seeking behaviors, and that elopement drills or additional supervision had not been implemented. The facility's policy required identification and intervention in situations where neglect was more likely to occur, including increased supervision for residents at risk. However, despite multiple staff members observing and documenting the resident's exit-seeking behaviors in the days leading up to the incident, no changes were made to her care plan or supervision level. The lack of timely intervention and failure to follow facility policy resulted in the resident being able to leave the facility unsupervised, placing her at risk.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for residents with behavioral changes that verbalize leaving the facility, exit seeking, wandering, and packing belongings should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all residents who were determined to be at risk for elopement to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident #1 to confirm details of the elopement.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and exiting the facility and to notify staff if a resident verbalizes thoughts of leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. All routine staff who cover the receptionist area were also in-serviced.
- A 100% audit of elopement binders was conducted by the Social Service Department to ensure the binders' information was reflective of all residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with key facility leadership and the Medical Director to review the incident and corrective actions.
Failure to Report Elopement and Neglect Incident to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of neglect and an incident of elopement involving one resident were reported to the appropriate agencies, including the State Agency, as required by state and federal law. On the date of the incident, a resident with a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, who had recently exhibited new exit-seeking behaviors, exited the facility unnoticed and unsupervised. The resident was missing for approximately fifteen minutes before being found by a CNA sitting in the passenger seat of the CNA's car in the facility parking lot, which was located near a busy four-lane boulevard with no barrier or crosswalk. The resident was then escorted back into the facility. Facility records, including the accident/incident log and progress notes, showed that the event was not documented as an elopement, and no incident report was completed. The progress notes indicated that the Unit Manager, DON, Social Worker, and Executive Director were notified of the incident. However, the Executive Director determined that the event was not an elopement because the resident stated she was waiting for her brother, despite the facility's policy requiring anyone taking a resident out to sign them out at the nurses' station. No one had signed the resident out or made arrangements for her to leave, and the resident had exited the building with a group of nursing students without staff knowledge. Interviews with staff confirmed that the incident was not reported to the State Agency or other required authorities at the time. The Executive Director, DON, and Receptionist all acknowledged awareness of the incident but did not initiate the required reporting procedures. The facility's policies on abuse prevention, missing residents/elopements, and investigation and reporting of violations all require immediate reporting of such incidents to the appropriate authorities, which was not followed in this case.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.
Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to initiate a thorough investigation into an allegation of neglect and an incident of elopement involving one of six sampled residents. On the specified date, a resident exited the facility unsupervised and was found sitting in a staff member's car in the facility parking lot. The resident had left the building unnoticed by staff during a shift change and was able to access an area adjacent to a busy four-lane boulevard. The staff member who discovered the resident escorted her back into the facility and notified the appropriate personnel, including the Executive Director and the Director of Nursing Services. Despite the incident, there was no documentation of the elopement in the facility's accident/incident log, and no incident report was completed. Multiple staff members, including LPNs and the Unit Manager, confirmed that they were aware of the resident's unsupervised exit but did not participate in any investigation or initiate missing resident procedures. No head count of residents was conducted, and the event was not reported to the State Agency as required. The Executive Director stated that the incident was not considered an elopement because the resident claimed she was waiting for her brother, and therefore, no report was made to any agencies. The resident involved had a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, but her most recent assessment indicated no cognitive impairment and no documented wandering or exit-seeking behaviors. The facility's policies required immediate investigation and reporting of such incidents, but these procedures were not followed. The failure to conduct a thorough investigation and report the incident placed the resident and others at risk, as identified by the State Agency, which cited the facility for failing to meet regulatory requirements regarding the investigation and prevention of alleged violations.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who cover the receptionist area, the receptionist was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social Service Assistants and Medical Director. The IP nurse was present by phone.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Behavioral and Medical Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in significant deficiencies. For one resident with a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, new wandering and exit-seeking behaviors were documented for at least a week prior to an incident where the resident eloped from the facility unnoticed and was outside unsupervised for approximately fifteen minutes. Despite staff observations and documentation of these behaviors, including packing belongings and attempting to leave, the care plan was not updated to address elopement or wandering risk. Progress notes indicated that interventions such as one-on-one observation and the application of a wander management device were initiated only after the elopement occurred, but these were not reflected in the resident's care plan. Multiple staff interviews confirmed that the care plan was not updated in response to the resident's behavioral changes, and the interdisciplinary team did not coordinate to ensure the care plan addressed the new risks. Another resident was admitted with a nephrostomy tube for urinary drainage due to obstructive uropathy. The hospital discharge summary and admission nursing assessment noted the presence of the nephrostomy tube, but the initial and comprehensive care plans did not include any focus, goals, or interventions related to nephrostomy tube care. There were no instructions for site care, flushing, dressing changes, or infection prevention, and the facility did not contact the physician or specialist for guidance on nephrostomy care upon admission. Staff interviews revealed that nursing staff relied on general practice rather than formal guidance, and the MDS Coordinator acknowledged that the absence of a care plan for the nephrostomy tube was an oversight. The DON and Medical Director both confirmed that the lack of a care plan for this specialized medical device was a failure in the care planning process and could result in missed or inconsistent care. The facility's policies required that care plans be person-centered, updated upon changes in condition, and include measurable goals and staff approaches for each identified problem or need. However, in both cases, the facility did not follow its own policies or regulatory requirements to ensure that care plans were comprehensive and updated in response to significant changes in residents' conditions or care needs. This failure led to a lack of clear instructions for staff and placed residents at risk for inadequate supervision and care.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident # 1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident# 1. Resident# 1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a decription.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clincial Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Identification
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent the elopement of a resident who had documented new wandering and exit-seeking behaviors for at least a week. The resident, who had diagnoses including bipolar disorder, anxiety, schizophrenia, a history of falls, and was assessed as at risk for falls and requiring supervision for walking, exited the facility unnoticed and was found sitting unsupervised in a staff member's car in the parking lot. The resident had been observed packing belongings, expressing confusion, and making statements about leaving, but these behaviors were not identified as exit-seeking or elopement risk by staff. Despite multiple staff members observing the resident's behavioral changes, including repeated trips to the front entrance and packing bags, the care plan was not updated to reflect the new risk, and no interventions such as wander management devices or increased supervision were implemented prior to the elopement. Documentation of the resident's change in behavior was reported to the primary healthcare provider, who ordered a urinalysis, but the facility did not recognize or address the increased risk of elopement. Staff interviews revealed a lack of awareness and action regarding the resident's behaviors, and no incident report was completed after the resident exited the facility. Additionally, facility policies and procedures were not followed, as evidenced by the absence of an updated care plan, missing elopement binders at the nurses' station, and lack of head counts or elopement drills following the incident. The front entrance could be opened with a code, and the receptionist, who was aware of the resident's behaviors, left the desk unattended without ensuring coverage. The facility did not report the incident to the State Agency in a timely manner, and there was no thorough investigation or immediate implementation of elopement precautions for the resident prior to the event.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.
Failure to Provide and Document Nephrostomy Tube Care
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a nephrostomy tube. Upon admission, the resident had a urinary obstruction requiring a nephrostomy tube, as documented in hospital discharge records and admission notes. However, there were no physician orders for nephrostomy tube care, such as flushing or dressing changes, and no care plan was developed to address the device. Throughout the resident's stay, there was no documentation of any nephrostomy tube dressing changes or flushes in the clinical record, and nursing notes did not indicate that these essential care tasks were performed. Interviews with nursing staff revealed that neither the RN nor the LPN responsible for the resident's care had performed or documented dressing changes or tube flushes. The RN stated she had not received specific orders or a schedule for nephrostomy tube care and assumed another provider was managing it. The LPN confirmed she only visually monitored the site and did not perform routine maintenance, as there were no care plan instructions or physician orders. Both staff members acknowledged that routine care should have been in place and documented, but it was not. The Director of Nursing confirmed that the facility's standard practice requires physician orders and regular care routines for invasive devices, including scheduled dressing changes and tube flushes, with documentation for each instance. Upon review, the DON acknowledged the absence of orders and documentation for nephrostomy care and described this as a failure in care. The Medical Director also stated that nephrostomy tubes require routine care and monitoring, and expected nursing staff to proactively obtain necessary orders and provide care. The lack of documentation and care for the nephrostomy tube was confirmed as a failure to follow professional standards of practice.
Failure to Implement Care Plan for Daily Skin and Foot Assessments
Penalty
Summary
Facility staff failed to implement care plan interventions for a resident with diabetes mellitus and end stage renal disease, specifically neglecting daily skin and foot assessments as required by the resident's care plan. The care plan included interventions to check the resident's body for skin breaks and to inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. Despite these directives, staff did not identify or document developing wounds on the resident's right foot. The wounds were first discovered and treated at an outside dialysis center, where significant skin breakdown and discoloration were noted, and the facility was notified of the findings. Upon the resident's return from dialysis, facility staff completed a weekly skin assessment but failed to document the wounds or the dressing applied by the dialysis center. The LPN responsible for the assessment could not confirm whether the skin check was actually performed. The wound care physician and wound care nurse were not consulted or made aware of the wounds until several days later, and the wounds remained untreated by facility staff for five days after being discovered by the dialysis center. Interviews with facility leadership confirmed that staff did not follow the care plan or respond appropriately to the external notification of the resident's condition.
Failure to Provide Timely Wound Care Following Notification from Dialysis Clinic
Penalty
Summary
Facility staff failed to provide necessary care and services and did not respond appropriately to changes in a resident's condition when wounds were identified and treated by a dialysis clinic. The dialysis staff discovered wounds on the resident's right foot, including missing skin and black discoloration, and notified the facility on the same day. Despite this notification, the facility did not assess or initiate treatment for the wounds until five days later. The resident reported that only the dialysis staff had changed his dressing, and no one from the facility had checked or treated the wounds during this period. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's foot wounds. The unit manager and wound care nurse were unaware of any issues, and there was no evidence in the 24-hour nursing reports or electronic medical record that the physician had been notified or that any interventions had been implemented. The facility's policies required weekly skin audits and prompt intervention for identified skin conditions, but the weekly skin assessment completed after the resident returned from dialysis did not document the wounds, and the wound care nurse could not confirm if the assessment had actually been performed. The resident had a history of end-stage renal disease and severe cognitive impairment. Observations at the dialysis center confirmed that the same dressing applied by dialysis staff remained unchanged for several days, and the facility's wound care physician did not receive a consultation order until five days after the initial notification. Facility leadership acknowledged that staff failed to ensure appropriate wound care, monitoring, and follow-up actions, despite being informed of the resident's condition by the dialysis clinic.
Failure to Follow Care Plan for Dialysis Access Site Dressing Removal
Penalty
Summary
The facility failed to implement a comprehensive care plan intervention for a resident who receives hemodialysis, specifically regarding the timely removal of a pressure dressing from the resident's dialysis access site. The care plan, dated 10/15/24, required that the pressure dressing be removed four hours post-dialysis unless otherwise specified, and the physician's order directed removal six hours after returning from dialysis. However, during an observation on 04/01/25, the resident was found to still have the bandage in place from a dialysis treatment that occurred the previous day, indicating the dressing had not been removed as required. Interviews with facility staff, including the Unit Manager, DON, and LPNs, confirmed that the care plan and physician's orders were not followed. The DON and LPNs acknowledged the failure to remove the bandage and to consult the care plan for guidance. The resident involved had a history of dependence on renal dialysis and was cognitively impaired, with a BIMS score of 6. The deficiency was identified through observation, record review, and staff interviews, all of which confirmed the lapse in following the established care plan and physician's orders.
Failure to Timely Remove Dialysis Access Site Dressing
Penalty
Summary
Facility staff failed to ensure the timely removal of a pressure dressing from a dialysis access site for a resident dependent on renal dialysis. The resident had a physician's order and specific instructions from the dialysis unit to remove the pressure dressing within four to six hours after returning from dialysis. Documentation on the Dialysis Information Update Transfer Form repeatedly indicated the required timeframe for dressing removal. Despite these clear instructions, the dressing remained in place well beyond the specified period, as confirmed by observation and staff interviews. The resident, who was visually impaired and unable to remove the dressing independently, reported notifying nursing staff to remove the bandage, but it was not done. The dialysis nurse stated that she had previously educated facility staff, including the DON and Administrator, about the importance of timely dressing removal. Both the DON and Administrator acknowledged that staff failed to follow the physician's order and dialysis instructions, and neither was aware that this was a recurring issue until it was brought to their attention.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in unmet care needs. For one resident with a history of bladder incontinence and an indwelling urinary catheter, the care plan did not address catheter care or include interventions related to the presence of the catheter. Observations confirmed that the resident's urine collection bag was left uncovered in a public area, and multiple staff members, including the MDS Nurse and Unit Manager, were unaware of the catheter's presence or the need for a care plan addressing catheter care and privacy measures. Another resident, who was dependent on staff for activities of daily living due to dementia, did not consistently receive scheduled showers as outlined in the care plan. The care plan specified assistance with showers three times weekly, but the resident reported not receiving showers on scheduled days and expressed dissatisfaction with having to request them. Staff interviews revealed confusion regarding the resident's shower schedule, and the CNA assigned to the resident was unable to confirm when the last shower was provided. The MDS Nurse acknowledged that care plans are developed and updated by nursing staff and that instructions are made available to CNAs through the facility's computer system. However, discrepancies between the care plan and the weekly shower list contributed to missed care. The Director of Nursing and Administrator confirmed the lack of a catheter care plan for the first resident and acknowledged the inconsistency in shower scheduling for the second resident.
Failure to Obtain Physician Order for Indwelling Catheter
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease, neuromuscular dysfunction of the bladder, and prostatic hyperplasia was found to have an indwelling Foley catheter in place without a corresponding physician order documented in the medical record. The resident had been admitted with the catheter in place, and staff interviews confirmed that the catheter had remained since admission. Despite facility policy requiring all physician orders to be written and signed, there was no order for the catheter itself, only an order for catheter care that was initiated after the resident had already been in the facility for an extended period. Observations revealed the resident seated in a wheelchair with an uncovered urine collection bag, and staff, including an LPN and the MDS nurse, were unaware of the need for a catheter order or the presence of the catheter. The DON and Administrator both confirmed that care should be provided according to physician orders and that the lack of a documented order for the catheter did not meet professional standards of care. The deficiency was further supported by the absence of a physician order in the resident's record and staff's lack of awareness regarding catheter care and monitoring.
Resident Dignity Compromised by Uncovered Urinary Catheter Bag
Penalty
Summary
A deficiency occurred when a resident's urinary catheter bag was left uncovered and visible in a public common area, specifically the Unit 2 Dining Room, with approximately eighty milliliters of urine visible. Multiple observations confirmed that the catheter bag was not covered, and this was witnessed by both facility staff and the survey team. The facility's policy on resident rights, which emphasizes privacy and dignity, was not followed in this instance. Interviews with staff revealed a lack of awareness and monitoring regarding the resident's catheter care. The LPN assigned to the resident was new to the facility and unaware of the need for a catheter bag cover. The MDS Nurse was also unaware that the resident had a catheter until it was pointed out during the survey. The Unit 2 Manager confirmed that the resident had an indwelling catheter since admission. The resident in question had severe cognitive impairment and diagnoses including chronic kidney disease, neuromuscular dysfunction of the bladder, and prostatic hyperplasia.
Failure to Provide Required Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide necessary care for hygiene, bathing, and grooming for two of eight sampled residents. One resident was observed with a long mustache and beard, with facial hair long enough to interfere with eating and cause discomfort. The resident expressed that the mustache hairs were bothersome and wished for them to be trimmed. Facility policy required residents to be free of facial hair unless otherwise documented in the care plan, and staff interviews confirmed that grooming, including shaving, was to be performed during AM and PM care or as needed. However, the resident's grooming needs were not met as required by policy. Another resident reported not receiving scheduled showers for at least two weeks, despite being dependent on staff for bathing and being scheduled for showers three times weekly. The resident stated that staff told him he could not be showered due to the lack of a shower bed, although observations confirmed that both a shower bed and a shower chair were available for use. Staff interviews revealed confusion regarding the resident's shower schedule and an inability to confirm when the last shower was provided. The resident continued to request showers, indicating that his hygiene needs were not being met according to facility policy and his care plan.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment for its residents, as evidenced by multiple observations during the survey. Resident #7's room was found with dried, glossy, tan-colored spots on the oxygen concentrator, infusion pole, and over-the-bed table. Additionally, the Day Room on Unit 4 was cluttered with trash, including food and other debris, while a resident was present in the room. Resident #8's room was observed to have a floor littered with various items, including candy wrappers, crayon wrap paper, and food remnants. The room also had a dusty and dirty air conditioner, a stained bed frame, and a privacy curtain with brown spots. Notably, there were roaches observed crawling on the floor and wall near the resident's bed. The Assistant Administrator confirmed the need for cleaning and acknowledged the presence of pests. Further observations revealed that Resident #2's room had numerous dried, glossy spots on the air conditioner, and Resident #4's room was littered with trash and had stained walls and furniture. Interviews with the Housekeeping Director and Maintenance Director highlighted issues with staffing and maintenance logs, contributing to the unsanitary conditions. The facility's Administrator acknowledged the conditions and mentioned hiring new housekeeping staff to address the issues.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely and routine incontinence care for a resident who required assistance with toilet use and hygiene. The resident, who had severe cognitive impairment and was always incontinent of bowel and bladder, was not checked or provided care for incontinence needs for a period of three and a half hours. This lapse occurred between 12:30 PM and 4:00 PM, during which time the resident was observed with wet incontinence briefs and clothing that smelled of urine. The facility's policy required that incontinent residents be checked at least every two hours, as needed, and upon request, but this was not adhered to in the case of the resident. Interviews with staff revealed that the Certified Nurses' Aide (CNA) assigned to the resident's care left after lunch without making rounds or checking on incontinent residents. The subsequent CNA, who took over at 1:30 PM, did not check the resident until 4:00 PM. The Licensed Practical Nurse (LPN) and the Director of Nurses (DON) confirmed that the resident was not monitored for incontinence during this period, and acknowledged that the delay in care was too long. The facility's failure to ensure timely incontinence care was further compounded by staffing issues, as repeated episodes of staff not working scheduled hours were noted to potentially affect resident care.
Failure to Adhere to Enteral Feeding Orders
Penalty
Summary
The facility failed to provide care and services to a resident with a feeding tube according to the resident's needs and consistent with the practitioner's orders. The deficiency was identified for a resident who relied on enteral feeding for nutrition. The facility's policy on enteral nutrition, dated 2017, outlined that tube feeding should be individualized, allowing for potential downtime for personal care or rehab therapy sessions. However, observations revealed that the resident's enteral feeding pump was turned off for over four hours, contrary to the physician's order to hold the feeding for only 30 minutes prior to meals. The Licensed Practical Nurse (LPN) expressed confusion regarding the physician's orders for the resident's enteral feeding, stating that the feeding was supposed to be turned off for an hour before the delivery of the resident's supper tray. The Director of Nursing (DON) confirmed that the feeding should not have been held for more than 30 minutes, as prolonged interruption could affect the resident's nutritional and hydration needs. The resident, admitted with diagnoses including Aphasia, Gastrostomy status, Diabetes, and Metabolic Encephalopathy, was observed with the enteral feeding pump off and the feeding bottle unchanged for several hours, indicating a failure to adhere to the prescribed feeding schedule.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents on eight out of sixteen staffing days reviewed in December 2024. Observations and interviews revealed that staff shortages led to inadequate care, such as delayed incontinence monitoring and care for residents. An anonymous complaint highlighted a lack of housekeeping staff and inadequate direct care staff, which was corroborated by staff interviews and record reviews. Certified Nursing Assistant (CNA) #1 reported being unable to provide timely care due to an increased workload after another CNA left mid-shift. Interviews with staff indicated that late arrivals and call-ins were common, affecting the facility's ability to maintain adequate staffing levels. The Staff Development Director admitted to not using the Facility Assessment Tool for scheduling, relying solely on census numbers, which contributed to the staffing issues. The Director of Nurses (DON) confirmed that call-ins were problematic and that staff sometimes left residents in bed or skipped showers due to low staffing levels. Additionally, CNAs were occasionally reassigned to work in the laundry due to a lack of housekeeping staff, further impacting resident care. Resident #1, who was admitted with diagnoses of Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes, reported waiting up to an hour for assistance on multiple occasions. The facility's staffing grid showed that the number of CNAs and licensed nurses often fell short of the required numbers based on the Facility Assessment Tool. The Administrator acknowledged the issues and confirmed that the Staff Development Director was expected to use the Facility Assessment Tool for staffing decisions, but this was not being done effectively.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the conditions observed in the rooms of two residents, a shower room, and a hallway. Resident #3's room was found to be dirty, with trash and stains on the floor, dusty windows, and a black substance on the windowsills. The resident expressed dissatisfaction with the housekeeping services, and the Housekeeping Supervisor confirmed that the room should have been cleaned daily. Additionally, a family member of Resident #3 reported consistent issues with cleanliness during their weekly visits. Resident #4's room and the surrounding hallway were noted to have a strong urine odor. The resident, who had a history of urinary incontinence, was waiting for assistance from a CNA to change her bedding. Both the CNA and an RN confirmed the presence of the odor, and the Administrator suggested that the mattress might need cleaning or replacement. This indicates a failure to promptly address the resident's incontinence needs and maintain a clean environment. The shower room on the back hall was observed to have brown stains on the floor, which were easily wiped away, indicating a lack of regular cleaning. The assigned housekeeper admitted to not cleaning the floor on the days in question due to her workload. Additionally, the hallway outside a resident's room had decorative items covered in thick dust and dirty hand sanitizer dispensers, which the Housekeeping Supervisor acknowledged needed cleaning. The Administrator confirmed that housekeeping services were expected daily, but staffing challenges were impacting the facility's ability to maintain cleanliness.
Failure to Ensure Proper Food Storage and Labeling
Penalty
Summary
The facility failed to ensure foods were stored safely in the walk-in refrigerator and freezer. During an initial tour of the kitchen, it was observed that clear containers with unknown substances were neither labeled nor dated with use-by dates. Additionally, containers and boxes of food were stored on the floor in the walk-in freezer. The facility's policies on labeling and dating foods, as well as food storage, were not followed, which require all foods to be properly labeled and stored at least six inches above the floor to prevent contamination. Interviews with the Registered Dieticians (RD #1 and RD #2) and the Administrator revealed that the Dietary Manager, who was responsible for labeling and dating potentially hazardous foods (PHFs) and ensuring proper food storage, had been out sick and decided not to return. The Administrator confirmed that the facility had recently undergone a Mississippi State Department of Health (MSDH) food establishment inspection and received a C rating. The dietary staff was expected to follow the food storage and labeling policies in place, but these expectations were not met, leading to the observed deficiencies.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The facility failed to ensure the attending physician was notified of repeated medication refusals for a resident. The resident, who had diagnoses including Metabolic Encephalopathy, Unspecified Dementia, and Atrial Fibrillation, refused medications eight out of 29 days in February 2024 and only took medications for three out of 13 days in March 2024. Despite the facility's policy requiring notification of the physician and responsible party after repeated medication refusals, this was not consistently done. The Director of Nursing confirmed that the nurse should document refusals and notify the physician and responsible party, but this procedure was not followed in this case. Interviews with the Pharmacy Consultant, the resident's Physician, and the Nurse Practitioner revealed that they were not aware of the extent of the resident's medication refusals. The Pharmacy Consultant stated he does not always review the eMAR, and the Physician and Nurse Practitioner were not informed of the numerous missed doses. The resident's Physician emphasized the importance of the missed medications, particularly Eliquis, which is critical for preventing further complications. The Nurse Practitioner noted that the facility's use of agency staffing might contribute to the inconsistency in medication administration. The resident's Resident Representative (RR) also confirmed that she was not notified of the medication refusals. The facility's documentation showed only three notes indicating that the Nurse Practitioner was notified and only one note stating that the Resident Representative was informed. The Director of Nursing and the Administrator admitted they were unaware of the extent of the medication refusals and confirmed there was no system in place to address the issue. The resident's Quarterly Minimum Data Set (MDS) indicated severe cognitive impairment, further highlighting the need for diligent medication management and communication with the responsible parties.
Failure to Provide Clean Linen for Residents
Penalty
Summary
The facility failed to maintain a clean, homelike environment by not ensuring clean linen was available for two residents. Resident #120 was observed lying in bed with a strong odor in the room, indicating a need for incontinent care. Despite turning on the call light, the resident did not receive the necessary care for 30 minutes, and the CNA revealed that there were no clean sheets available. The resident had to sit up in a chair because of the lack of clean sheets, a situation that reportedly occurred several times a week. Resident #120 had severe cognitive impairment and multiple diagnoses, including seizures and diabetes mellitus. Resident #194 was found lying in bed without a fitted sheet on the mattress and stated that the facility often ran out of sheets. The resident, who was cognitively intact and required moderate assistance for mobility, confirmed that this issue was recurrent. Interviews with the DON, laundry supervisor, and other staff revealed that the facility had linen available, but staff were either unaware of its location or used the lack of linen as an excuse not to change beds. The facility had previously conducted an in-service training on linen locations, but many of the trained staff no longer worked at the facility.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by not administering medications per physician's orders for four out of 33 medications, resulting in a 12.12% medication error rate. Specifically, a Licensed Practical Nurse (LPN) administered Aspirin, Sertraline, Multivitamin with minerals, and Amlodipine to a resident via a PEG tube, despite the physician's orders indicating these medications were to be given by mouth. The LPN confirmed the error after reading the medication orders post-administration. The Director of Nursing (DON) reviewed the medication orders and confirmed that the medications were indeed ordered to be given by mouth. The DON stated that any variation from the physician's orders would be considered a medication error. The resident's physician orders, dated from November 2023, specified the oral administration of the medications, which was not followed, leading to the identified deficiency.
Unpalatable and Unappealing Food
Penalty
Summary
The facility failed to serve food in a manner that was appealing and palatable for two residents. Resident #5, who has Type 2 Diabetes Mellitus and Iron Deficiency Anemia, stated that the food tasted like slop and only consumed cold cereal and milk. This resident was cognitively intact with a BIMS score of 15. Similarly, Resident #362, who has diagnoses including Encounter for other Orthopedic Aftercare and Essential Hypertension, complained that the food tasted bad and was not appealing. This resident also had a BIMS score of 15, indicating cognitive intactness. On a subsequent day, a lunch tray was tested with the Dietician, revealing that the vegetables were bland and lacked taste. The Dietician acknowledged that the carrots could be sweeter and noted that some residents complain about the food being too salty or spicy. Resident #362 ate only 50% of the lunch meal and had previously complained to a CNA about the food, preferring fresh fruits and vegetables, which she kept in her personal refrigerator. These observations and interviews indicate that the facility did not meet the requirement to ensure food and drink were palatable, attractive, and at a safe and appetizing temperature.
Failure to Provide Scheduled Smoking Breaks
Penalty
Summary
The facility failed to ensure that residents who smoked were allowed to exercise their right to smoke during the designated smoking times. Resident #6 reported not receiving scheduled smoking breaks and observed staff engaging in horseplay instead of assisting residents. Resident #6, who has a diagnosis of Nicotine Dependence and is cognitively intact with a BIMS score of 15, expressed frustration and felt disrespected by the staff's inaction. Similarly, Resident #27 reported inconsistent smoking breaks, with delays of up to an hour or missed breaks entirely. Resident #27, also diagnosed with Nicotine Dependence and cognitively intact with a BIMS score of 13, observed staff idling at the nurse's desk during scheduled smoking times, further contributing to feelings of frustration and disrespect. Interviews with staff, including a CNA and the Director of Nursing, confirmed that residents were often ready for their smoke breaks, but staff were not available to assist them. The Director of Nursing acknowledged the issue and indicated that Unit Managers were responsible for assigning CNAs to take residents out for their smoke breaks. The Administrator, who had only been at the facility for three weeks, stated that he was still acclimating to the facility but expected staff to honor residents' preferences. The failure to provide scheduled smoking breaks negatively impacted the residents' feelings and their right to self-determination.
Failure to Resolve Grievance Related to ADL Care and Showering
Penalty
Summary
The facility failed to resolve a grievance related to Activities of Daily Living (ADL) care and showering for a resident with severe cognitive impairment. The resident, who has diagnoses including cerebrovascular disease, type 2 diabetes mellitus, unspecified convulsions, and essential hypertension, reported not receiving scheduled showers on multiple occasions. Despite being scheduled for showers three times a week, the resident only received bed baths during the observed period, leading to discomfort and complaints about dirty and itchy hair. Interviews with various staff members, including CNAs, social services, and nursing supervisors, revealed inconsistencies in the care provided to the resident. The resident's daughter had previously filed a grievance regarding the lack of proper ADL care, which led to an interdisciplinary team meeting and staff in-service. However, the grievance remained unresolved as the resident continued to miss scheduled showers, and staff were unaware of the ongoing issue. The facility's grievance policy requires prompt resolution of grievances, but the staff failed to follow through effectively. Social services and nursing leadership were not adequately monitoring the situation, and there was a lack of communication and documentation regarding the resident's care needs. The facility's reliance on agency staff further contributed to the inconsistency in care, as new staff were unfamiliar with the resident's specific requirements.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to ensure timely incontinent care for a resident, leading to the resident being left soiled for extended periods. Resident #167, who is dependent on staff for activities of daily living and is incontinent of bowel and bladder, reported having to wait long periods to be changed, especially during the night shift. Observations confirmed that the resident was found heavily soiled with urine and bowel movement, with a pillowcase placed between her legs to absorb the urine. The resident and her daughter had previously complained to staff about the issue, but the problem persisted. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in care practices and a lack of timely response to the resident's needs. The DON confirmed that residents should be checked and changed every two hours or more frequently as needed, but this standard was not met. The facility's policy on incontinent care was not followed, leading to the resident's prolonged discomfort and potential health risks. The facility's interdisciplinary team was aware of the complaints but failed to address them effectively.
Latest citations in Mississippi
A resident with hemiplegia, hemiparesis, and cognitive impairment had a care plan directing staff to apply and remove a right ankle splint at specific times each day and to provide passive stretching to prevent decline in ROM. Observation found the splint not in use and lying on a chair, and the resident was unsure when it was last applied. A PTA reported the resident had developed foot drop and that the splint could no longer be applied without additional therapy, attributing this to the splint not being used daily as ordered. The DON confirmed that staff failed to follow the established care plan for splint application and ROM management.
A resident with hemiplegia and hemiparesis after a cerebral infarction, and severe cognitive impairment (BIMS 5), had physician and therapy orders for right-hand and right-ankle splinting with passive ROM to manage contractures and maintain ROM. Surveyors observed a foot splint lying unused and the resident’s right hand contracted into a fist without a hand roll. The resident could not recall when the foot splint was last applied and reported never having a hand roll. An LPN was unaware of the need for the splint and confirmed no hand roll was in use. Records showed the hand splint order was discontinued at the responsible party’s request due to pain, but OT was not notified and no alternative such as a hand roll was initiated. PT had documented improved ankle ROM and recommended a PODUS boot, while a PTA later reported the resident had developed foot drop related to the ankle splint not being applied as ordered. The DON confirmed that daily ankle splint orders existed and that the hand splint was discontinued without alternative interventions to prevent contracture.
The facility failed to protect resident narcotic medications from misappropriation when an LPN handed over a medication cart’s narcotic keys to an RN without performing required narcotic counts before and after the transfer, and the cart was later found unlocked in the nurses’ station. During the subsequent shift change count, staff discovered multiple missing doses of oxycodone-acetaminophen and hydrocodone-acetaminophen prescribed PRN for pain to four residents with conditions including dementia, COPD, dysphagia, and diabetic neuropathy. Review of individual controlled drug logs showed corrected balances to account for the missing tablets, confirming that controlled substances were unaccounted for during the period of unsecured cart access and improper key control.
Two ambulatory residents with dementia, severe cognitive deficits, and known wandering behavior, each wearing a wander guard bracelet, were able to exit through a unit door when a visitor held it open, despite the door alarm sounding and prior observations that they frequently walked together and approached doors. An LPN responded to the alarm and, along with other staff, initiated a search when the residents could not be found on the unit; staff ultimately located the residents across a four-lane highway and returned them to the building without injury. The incident occurred despite facility policies requiring use of a security system for residents unable to protect themselves from harm by wandering, and staff and leadership acknowledged that the residents had a history of walking the halls together and going to doors, and that increased monitoring and restricting visitor access to door codes could have prevented the elopement.
A cognitively impaired resident with dementia, agitation, and a history of wandering was previously assessed by the IDT as not being at risk for elopement and did not have elopement precautions in place. On one occasion, a visitor exited through the front door without realizing the resident followed outside, and staff later discovered the resident alone on the front porch after being missing for several minutes. An LPN and CNA participated in locating and returning the resident, and the incident revealed that supervision and elopement risk assessment were insufficient for this resident.
A resident with Type 2 DM and moderately impaired cognition had two unstageable heel DTIs documented on the MDS and physician orders for treatment to both heels, but the comprehensive care plan did not include any problem, goals, or interventions related to these pressure injuries. LPNs responsible for MDS and care plan completion acknowledged the omission and stated that although they periodically audit by comparing orders to the care plan, this situation was missed. The DON reported she expected the wound care nurse to update the care plan with new wound treatment orders, while an RN stated she could update interventions but had not been trained to create a new focused care plan and was unaware it was her responsibility to add the DTI treatment orders to the care plan.
A controlled substance prescribed for a cognitively intact resident with a left femur fracture was delivered and signed for by an LPN but was not entered on the narcotic accountability record or narcotic box package count and was later found to be missing. One LPN reported receiving the blister pack of thirty Hydrocodone/Acetaminophen 10-325 mg tablets from another LPN, placing it on the nurses’ station, and leaving the area, while both LPNs stated they were in the medication room as the medication remained unattended. The DON and Administrator confirmed that staff failed to secure the controlled medication as required by facility policy and that the missing tablets could not be located.
Surveyors found that staff failed to properly secure and store medications for two residents. For one resident, an LPN received a delivery of Hydrocodone-Acetaminophen, passed it to another LPN, and the controlled medication was left unattended at the nurses’ station instead of being immediately locked and entered into the narcotic count, after which it could not be located. For another resident, two bottles of Lorazepam oral concentrate, documented on the narcotic record and labeled to be protected from light and refrigerated, were observed stored in a locked medication cart rather than in the designated medication refrigerator, even though staff acknowledged knowing the manufacturer’s refrigeration requirement.
A resident with hemiplegia and hemiparesis following cerebral infarction was transferred by facility van to a psychiatric hospital for evaluation and was later determined by the facility to be discharged due to aggressive behavior and threats, with staff stating they could not meet the resident’s needs. The Administrator and Social Services Director communicated with the psychiatric facility and the resident’s family about finding alternative placement and informed the family the resident would not be allowed to return, but no formal involuntary discharge notice or written appeal rights were provided, and no physician discharge order was documented, contrary to facility policies requiring a completed transfer form and written notice of transfer/discharge with appeal information.
The facility did not adequately investigate, address, or resolve repeated grievances about food quality and temperature raised through Resident Council meetings. Over several months, residents reported that weekend meals were bad, food was consistently cold, beverages lacked sufficient ice, and breakfast items were hard or unpalatable. While limited steps such as using temperature-holding containers, sending trays out faster, and in-servicing dietary staff were noted, there was no documented monitoring, follow-up, or evaluation of effectiveness. Cognitively intact residents continued to report cold, poor-tasting food, and staff, including the Dietary Manager and Social Services, acknowledged awareness of the complaints without evidence of thorough follow-up or resolution.
Failure to Implement Care Plan for Ankle Splint and ROM Management
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for contracture management and splinting to prevent decline in range of motion for one resident. The facility’s policy on prevention of decline in range of motion required that, based on the comprehensive assessment, the facility provide interventions, exercises, and/or therapy to maintain or improve ROM. The resident’s care plan, initiated on 8/1/25, identified an ADL self-care performance deficit related to stroke, hemiplegia, and immobility, placing the resident at risk for functional decline. The care plan interventions directed staff to apply a splint to the right ankle after breakfast, provide passive stretch to the right ankle after applying the splint, remove the splint at lunchtime, reapply the splint after supper with passive stretch, and remove the splint at bedtime. On observation, the resident’s ankle splint was not in use and was found lying in a chair in the resident’s room, and the resident was unsure when the splint was last applied. The PTA reported that the resident had developed foot drop and that the ankle splint could no longer be placed without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON stated that the care plan was used to inform staff how to care for the resident and verified that staff failed to follow the care plan when they did not apply the ankle splint. Record review showed the resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and an MDS assessment indicated a BIMS score of 5, reflecting cognitive impairment at the time of the deficiency.
Failure to Implement ROM and Splinting Orders Resulting in Contractures and Foot Drop
Penalty
Summary
The facility failed to provide ordered range of motion (ROM) and splinting interventions to prevent decline in ROM for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident was admitted with these diagnoses and had physician orders and therapy recommendations for contracture management and splinting. An OT evaluation documented decreased ROM in the right upper extremity and recommended a resting hand splint and a restorative splint and brace program, with a subsequent OT evaluation recommending continuation of the contracture management and splinting program. A physician order directed staff to apply a right-hand splint after breakfast, provide passive stretch to the right elbow, wrist, and hand once daily, and remove the splint before dinner. Another physician order required application of a right ankle splint after breakfast and after supper with passive stretching following application. The facility’s own policy stated that residents without limited ROM should not experience a reduction in ROM unless clinically unavoidable. During observation, surveyors noted a foot splint lying unused in the resident’s chair and the resident’s right hand contracted into a fist without a hand roll in place. The resident reported not knowing when the foot splint was last applied and stated she had never had a hand roll. An LPN stated she did not know why the splint was in the room, believed the resident was not required to wear it, and confirmed the resident did not have a hand roll. Record review showed the right-hand splint order was discontinued at the responsible party’s request due to pain, but the OT reported she had not been notified of this discontinuation and stated a hand roll should have been initiated when the splint was stopped; she further stated the resident’s hand was now contracted into a fist. A PT discharge summary documented improved right ankle ROM with therapy and recommended a PODUS boot daily for up to five hours, while a PTA later reported the resident had developed foot drop and that the ankle splint could no longer be applied without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON verified that there were physician orders for daily ankle splinting and acknowledged that the right-hand splint was discontinued without alternative interventions to prevent contracture. The resident’s MDS showed a BIMS score of 5, indicating severe cognitive impairment.
Failure to Secure Narcotic Medications and Maintain Key Control
Penalty
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.
Failure to Prevent Elopement of Two Cognitively Impaired Wanderers
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents with known wandering and elopement risk. Both residents were ambulatory, frequently walked throughout the facility together, and were known to staff as wanderers. Each resident had a diagnosis of dementia with severe cognitive deficits documented on their MDS assessments, and both had Wander/elopement alarms (wander guard bracelets) in place and used daily. The facility’s elopement/wandering policy stated that residents who are incapable of adequately protecting themselves and unable to determine when they are at risk for harm by wandering out of the facility should be placed on the resident security system to ensure safety. On the day of the incident, video surveillance later reviewed by the Administrator showed that a visitor entered an exit door on the B Unit at approximately 6:20 PM. The two residents at risk for elopement approached the door, and the visitor held the door open, allowing them to walk out of the building. The residents were wearing wander guard bracelets, and when they exited, the door alarm sounded. A nurse responded immediately to the alarm, exited the facility, and went down the walkway but did not see the residents. Staff were then alerted that the residents were missing, and a facility-wide search was initiated. Staff interviews and the facility’s documentation confirmed that the residents had previously been observed walking together throughout the facility and approaching doors, including the exit door involved in the incident. The Administrator reported that review of the video showed the two residents had approached the same door together two or three times prior to the elopement event. Despite their known patterns of wandering, severe cognitive impairment, and prior door-approach behavior, the residents were able to exit the facility unnoticed and unsupervised when the visitor held the door open. Staff ultimately located the residents across a four-lane high-capacity highway approximately 528 feet from the exit door and returned them to the facility, where body audits and assessments documented no injuries and intermittent confusion. The State Agency determined that the facility’s failure to provide adequate supervision to prevent the elopement of these residents, who had exhibited exit-seeking behaviors, placed them and other residents at risk for wandering and elopement in a situation likely to cause serious injury, harm, impairment, or death and cited the facility at F689 with Immediate Jeopardy and Substandard Quality of Care. The residents’ medical records and elopement reports documented that both were confused, had impaired memory, and were identified as wanderers. One resident had a BIMS score of 3 and the other a BIMS score of 0, both indicating severe cognitive deficits. Progress notes and elopement reports recorded that staff were notified when the residents were not on the unit and could not be located, that all staff were engaged in searching, and that the residents were ultimately found outside and assisted back into the building. Interviews with CNAs and an LPN described hearing a Code W called, running outside, and seeing the residents across the street after they had crossed the four-lane highway. The DON acknowledged that the residents were always walking in the facility, often together, and that they had wandered to doors and looked out, and agreed that increased monitoring and not allowing visitors to have door codes could have prevented the residents from leaving the building.
Removal Plan
- Conducted a facility search.
- Notified police of missing residents.
- Director of Nursing interviewed staff and residents.
- Notified the Medical Director and residents’ families.
- Administrator and Director of Nursing checked the wander guard system and facility doors to ensure proper functioning.
- Returned Resident #1 and Resident #2 to the facility.
- Completed an incident report.
- Completed an emergency Quality Assurance meeting.
- Initiated in-service training for all staff on the elopement policy, including a quiz to validate comprehension, and required staff (including contract staff) to complete the in-service before working their next scheduled shift, with Administrator monitoring compliance.
- Responded immediately to the door alarm by sending staff outside to locate residents and notifying additional staff to assist with the search.
- Reviewed video surveillance and confirmed a visitor held the door open allowing residents to exit.
- Held an emergency Quality Assurance meeting with the Medical Director, Director of Nursing, Administrator, Regional Director, involved staff, and Infection Preventionist.
- Changed the main entry door code.
- Verified entrance door signage was in place instructing not to allow residents to exit unaccompanied.
- Identified residents at risk for elopement and ensured elopement bracelets/transmitters were functional and doors were locking appropriately.
- Reviewed care plans for residents at risk for elopement.
- Completed body audits on Resident #1 and Resident #2.
- Conducted audits verifying resident location, elopement risk, and wander guard bracelet function.
- Medical Records updated care profiles of residents at risk for wandering.
- Assistant Administrator began audits of all doors for function and security.
- Provided in-services on elopement policy and procedure, Resident Rights, and incident and accident reporting.
- Conducted elopement drills on each shift.
- Implemented monitoring systems to sustain compliance.
- Director of Nursing to monitor wander guard system checks three times weekly for four weeks or until substantial compliance is attained.
- Director of Nursing to monitor resident behavior for elopement attempts via incident reports, observations, and communications weekly for four weeks or until substantial compliance is attained.
- Quality Assurance Committee to meet for four weeks to review compliance with the plan of action, then continue routine Quality Assurance monitoring if no further concerns are noted.
- Administrator to hold follow-up Quality Assurance meetings monthly for two months then quarterly thereafter to ensure sustained compliance.
- Updated entry screening kiosk to include an additional reminder and attestation to ensure resident safety, requiring visitors to agree that no resident comes in or out with them and triggering a staff alert if the visitor refuses.
- Administration spoke directly with the visitor to confirm visitor policies and procedures.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident with a history of wandering from exiting the building unattended. The resident had diagnoses including dementia with agitation and a BIMS score of three, indicating severe cognitive impairment. The resident had been readmitted from a geriatric psychiatric hospitalization and was known by the DON to have a history of wandering. Despite this, the interdisciplinary team had previously determined that the resident was not at risk for elopement, and no elopement interventions such as a wander guard were in place at the time of the incident. On the day of the event, a visitor observed the resident standing near the front door and exited the facility without realizing the resident followed him outside. Staff later became aware that the resident was missing, and an LPN assisted in locating the resident. A CNA ultimately found the resident outside on the front porch and returned the resident to the facility, with the investigation determining the resident had been outside unattended for approximately five minutes. Staff interviews confirmed that the resident ambulated in the halls and had not previously attempted to exit the building, and that the resident was only reassessed and provided with a wander guard after the incident.
Failure to Care Plan for Pressure Injuries and Treatment Orders
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with pressure injuries. The facility’s undated Care Plan Policy and Procedure stated that each resident’s care plan would remain current and inform staff of needs, strengths, goals, and approaches, and that a comprehensive person-centered care plan would be completed as needed. Record review showed that the resident was admitted with Type 2 Diabetes Mellitus with ketoacidosis without coma and, per the Discharge MDS with an ARD of 1/19/26, had a BIMS score of 12 indicating moderately impaired cognition. Section M of the MDS documented two unstageable pressure injuries presenting as deep tissue injuries (DTIs). Physician orders dated 12/10/25 directed treatment to right and left DTI pressure ulcers. Despite these documented DTIs and treatment orders, review of the resident’s comprehensive care plan revealed no care plan addressing the DTIs on the left and right heels, which was inconsistent with the physician orders. During interviews, two LPNs responsible for MDS and care plan completion confirmed that the care plan did not include the DTIs and stated that care plans are developed based on the MDS and physician orders, and that audits comparing orders to care plans are done periodically but this had been missed. The DON stated her expectation that the wound care nurse update the care plan with new wound care treatment orders. An RN reported she could update care plan interventions but had not been trained to develop a new focused care plan and had not added the physician’s DTI treatment orders to the care plan, and she was not aware it was her responsibility to do so.
Unsecured Controlled Medication Left Unattended and Lost
Penalty
Summary
The facility failed to prevent misappropriation of resident property when a controlled substance prescribed for a resident was left unattended and subsequently went missing. Facility policies on abuse and neglect defined misappropriation of resident property to include missing prescription medications or diversion of resident medications, including controlled substances, and the Medication-Controlled Substances policy required that only authorized licensed nursing and pharmacy personnel have access to controlled medications, that all controlled substances be stored in a locked cabinet or compartment, and that accurate accountability of all controlled drugs be maintained. Despite these policies, a pharmacy courier delivered thirty Hydrocodone/Acetaminophen 10-325 mg tablets for a resident with a left femur fracture, and the medication was signed for by an LPN but was not signed onto the narcotic accountability record, was not documented on the narcotic box package count, and could not be located. The resident, who was cognitively intact with a BIMS score of 15 and had a physician’s order for Hydrocodone/Acetaminophen, was later informed that the tablets delivered had been lost. Interviews revealed that one LPN received the blister pack of thirty Hydrocodone/Acetaminophen tablets from another LPN and placed it on the nurses’ station before leaving the area, leaving the controlled medication unattended. Both LPNs reported being in the medication room while the medication remained unattended at the nurses’ station. The DON reported being notified that the medication was missing and that an investigation confirmed the medication could not be located and had been left unattended, and the Administrator confirmed staff failed to ensure controlled medications were secured and accessible only to authorized personnel and that the facility was unable to determine the location of the missing medication.
Failure to Secure Controlled Drugs and Follow Refrigerated Storage Requirements
Penalty
Summary
The deficiency involves the facility’s failure to store and secure medications, including controlled substances, in accordance with professional standards and manufacturer instructions. For Resident #1, who was admitted with a left femur fracture and was cognitively intact with a BIMS score of 15, the physician ordered Hydrocodone-Acetaminophen 10-325 mg tablets. A facility investigation documented that a pharmacy courier delivered 30 tablets of this controlled medication, which were received and signed for by an LPN but were never documented in the narcotic count system and were later unable to be located. One LPN reported that after receiving the Hydrocodone-Acetaminophen from another LPN, she left the medication unattended at the nurses’ station while she completed other tasks instead of immediately securing it in the locked medication cart. The LPN who initially received the medication from the courier confirmed that the controlled medication had not been immediately secured in the locked cart following delivery. For Resident #3, who was admitted with heart disease and had a BIMS score of 10 indicating moderately impaired cognition, the physician ordered Lorazepam (Ativan) oral concentrate. The narcotic record showed that two containers of Lorazepam were signed into the narcotic record on the date of admission. Manufacturer prescribing information for the Lorazepam oral concentrate specified that it must be protected from light and stored refrigerated at 36–46°F. During a controlled drug count, surveyors observed that two bottles of Lorazepam oral concentrate for this resident were stored in the locked medication cart rather than in a refrigerator, despite the label instructions requiring refrigeration. One LPN confirmed the manufacturer’s storage instructions on the label but was unsure why the medication had not been refrigerated, and another LPN acknowledged awareness that the medication required refrigeration but confirmed it had been stored in the medication cart instead of the designated medication refrigerator.
Failure to Provide Required Involuntary Discharge Notice and Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of an involuntary discharge, including appeal rights, and to obtain a physician’s discharge order before refusing readmission of a resident following a hospital transfer. Facility policy titled “Transfer Form” stated that it is the policy of the facility to provide a completed and accurate transfer form to residents transferred or discharged from the facility, and the policy titled “Appealing a Transfer or Discharge Notice” stated that residents have the right to appeal transfer or discharge notices and, upon notice of transfer or discharge, will be provided with a statement of their right to appeal. Record review showed that the resident, admitted with hemiplegia and hemiparesis following cerebral infarction, left the facility by facility van to be admitted to a psychiatric hospital for evaluation. Progress notes dated several days after the transfer documented that the resident had been discharged from the facility due to aggressive behavior and that, per conversation with the psychiatric hospital, the Administrator and Social Services Director would assist in finding alternative placement and home health if needed. Documentation further indicated that, due to threats made, the facility stated it was unable to meet the resident’s needs and communicated with the resident’s family that the resident would not be allowed to return. During interview, the Administrator confirmed that neither the resident nor the family was provided a formal involuntary discharge notice or information on appeal rights and that no physician order for discharge could be located, acknowledging that the formal notice, appeal rights, and physician order should have been obtained prior to discharge.
Failure to Investigate and Resolve Ongoing Food-Related Grievances
Penalty
Summary
The facility failed to ensure that grievances voiced through the Resident Council regarding food quality and temperature were thoroughly investigated, addressed, and resolved. Resident Council minutes over multiple months documented repeated complaints that weekend food was "bad," tasted sweet, and that food was cold by the time it reached residents. Additional concerns included insufficient ice in water and tea, hard breakfast biscuits and toast, and cold grits. Although the facility’s grievance policy stated that residents and families could voice grievances without reprisal and that the facility would make prompt efforts to resolve grievances, there was no documentation that the initial complaint about weekend food quality was addressed, and subsequent complaints continued without evidence of thorough investigation or resolution. Resident Council Department Response Forms showed limited actions, such as placing food in containers to maintain temperature, conducting an in‑service for dietary staff, sending food out faster, and instructing staff to pass trays promptly, but there was no documentation of monitoring, follow‑up, or evaluation of whether these measures were effective. Residents interviewed, all cognitively intact per their MDS BIMS scores, consistently reported that the food remained cold and did not taste good, with one resident noting that staff would reheat food only if requested. The Dietary Manager acknowledged awareness of the complaints and stated he had spoken with weekend staff and made changes like replacing tray carts and providing guidance on food preparation, but confirmed there was no documentation of ongoing monitoring or additional interventions. Social Services and the Administrator both acknowledged awareness of the complaints and that additional follow‑up and resolution efforts should have occurred, yet no evidence of such follow‑up was present in the records.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
