Diversicare Of Amory
Inspection history, citations, penalties and survey trends for this long-term care facility in Amory, Mississippi.
- Location
- 1215 Earl Frye Drive, Amory, Mississippi 38821
- CMS Provider Number
- 255119
- Inspections on file
- 19
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Diversicare Of Amory during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of cerebral infarction reported that a CNA was consistently rude, disrespectful, rushed, and too rough during care, despite the resident’s polite requests. Facility grievance documentation and the Administrator’s interview confirmed that the CNA did not provide gentle care and that the resident’s right to dignity and respect, as outlined in facility policy, was not honored. Progressive discipline records showed ongoing concerns from staff, residents, and family about the CNA’s rough handling of patients, delayed assistance, and absence from the assigned hallway, even though the CNA had previously completed abuse/neglect and resident rights training.
The facility did not ensure that new LPNs and CNAs received and completed required skills competency checkoffs before providing care. One new nurse worked independently without a preceptor or skills review, and documentation for two CNAs lacked signatures and verification of completed competencies. The Clinical Educator and Administrator confirmed that skills checkoffs were not completed or documented for these new hires.
A CNA verbally threatened a cognitively intact resident by stating she would slap him and put him in the morgue during an argument after closing a door in his face. Two other residents, also cognitively intact, corroborated hearing the threats and the argument. The CNA admitted to cursing at the resident, and the administrator confirmed this conduct met the facility's definition of verbal abuse.
The facility's QAPI committee failed to maintain and monitor interventions after a recertification survey, leading to repeated deficiencies. Significant staff turnover, including the Infection Control Nurse/Educator, contributed to the halting of EMBRACE rounds, which are designed to identify and correct issues. While issues were identified, follow-up was insufficient, resulting in persistent deficiencies.
The facility failed to implement adequate infection control measures, including monitoring for Legionella, proper storage of respiratory equipment, and adherence to Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling devices. Maintenance staff did not document water safety measures, and respiratory equipment was improperly stored on the floor. Staff also failed to use EBP during wound care and IV administration, increasing infection risk.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. A resident with Chronic Kidney Disease did not have vital signs documented before and after dialysis sessions, while another with pressure ulcers did not receive proper wound care due to the lack of enhanced barrier precautions. Other residents experienced issues with personal hygiene, Activities of Daily Living (ADLs), TED hose application, and respiratory equipment storage, indicating a broader failure in care plan implementation.
The facility failed to maintain personal hygiene for three residents, resulting in long, dirty fingernails and unkempt appearances. A resident with Hemiplegia had long, dirty nails, while another with Traumatic Subdural Hemorrhage had dirty, jagged nails and unkempt facial hair. A third resident had long ear hair and jagged nails. Staff confirmed the lack of care, acknowledging potential risks of bacterial spread and skin concerns.
The facility failed to provide appropriate treatment and care for two residents. One resident did not receive TED hose as ordered for orthostatic blood pressures, and staff were unaware of the order. Another resident had untreated skin tears with no treatment orders, risking infection and delayed healing. Observations and staff interviews confirmed these deficiencies.
The facility failed to store controlled drugs in a locked, permanently affixed compartment. An unopened box of Lorazepam Concentrate was found on a refrigerator shelf among non-narcotic medications, rather than in the secure lock box. An LPN confirmed the improper storage, and the DON noted the lock box was full, which may have led to the issue. She stated staff should have informed her, as improper storage could lead to missing medications and potential diversion.
The facility failed to provide a safe, clean, and homelike environment for its residents. Observations revealed rusted and damaged overbed tables, a wheelchair with a torn armrest and unclean frame, and a bathroom with unsanitary conditions. The DON confirmed these issues, which affected residents with moderate cognitive impairments and various medical conditions.
The facility failed to allow residents to smoke during inclement weather, despite having a pavilion for shelter. Residents, including those with nicotine dependence, were unable to exercise their right to smoke due to a policy prohibiting smoking during bad weather. Staff confirmed the enforcement of this policy, and the facility's admission paperwork did not inform residents of these restrictions.
A facility failed to include personal hygiene interventions in a baseline care plan for a resident with moderate cognitive impairment and a diagnosis of Traumatic Subdural Hemorrhage. Observations revealed the resident had jagged, dirty fingernails and unkempt facial hair. The DON confirmed the care plan did not address ADL care, despite the resident's need for assistance.
A facility failed to maintain ongoing communication with a dialysis center for a resident with Chronic Kidney Disease Stage 5, leading to incomplete documentation of pre-and post-dialysis vital signs. This deficiency resulted in billing issues for dialysis services, as communication sheets were not consistently completed or sent. The facility's staff, including the DON and Administrator, were unaware of the missing records, with the last communication recorded in the previous year.
The facility failed to maintain accurate reconciliation and accounting for controlled medications in one of the narcotic storage areas. An LPN gave the medication cart keys to the Medical Records nurse, violating policy. Narcotics in the medication room refrigerator were not counted during shift change reconciliation, leading to a deficiency in controlled substance accountability.
A facility failed to include a stop date for a PRN Ativan order for a resident with dementia, leading to a deficiency. The resident received the medication for anxiety and agitation, particularly on shower days, without a stop date for re-evaluation. The absence of a stop date was confirmed by an RN, and the DON explained its necessity for ongoing assessment.
The facility failed to honor the beverage preferences of two residents during dining observations. One resident, moderately cognitively impaired, requested a large glass of tea but was only given a small one due to family concerns about caffeine. Another resident, severely cognitively impaired, requested coffee at lunch but was denied as coffee was only served at breakfast. The Memory Care Coordinator and Administrator confirmed that residents' preferences should be honored, and coffee was available throughout the day.
A resident with Alzheimer's Disease was inappropriately restrained by a CNA in the Memory Care Unit, who prevented her from standing up by placing a knee between her legs. The resident, who was anxious and repeatedly requested to use the bathroom, was told to remain seated despite being on a toileting program. The facility's staff confirmed that the CNA's actions were not in line with the policy on residents' rights.
The facility failed to deliver mail to residents on Saturdays, as confirmed by resident council feedback and staff interviews. Despite a policy ensuring prompt mail delivery, residents reported not receiving mail on Saturdays, with mail left for the social worker to distribute during the week. The administrator was unaware of this issue, although a manager was supposed to handle mail distribution on Saturdays. All affected residents were cognitively intact.
The facility failed to mail written notifications of hospital transfers to the Resident Representatives for two residents. One resident was transferred following a fall, and another due to altered mental status. Social Services did not send the notifications, as the staff member was unaware it was her responsibility. The facility's policy requires such notifications, but they were not provided in these cases.
A facility failed to accurately complete an MDS medication assessment for a resident, incorrectly coding an antiplatelet medication as an anticoagulant. The resident, admitted with Cerebral Ischemia, was prescribed Brilinta, an antiplatelet, but the MDS inaccurately reflected this as an anticoagulant. Interviews with the MDS Coordinator and DON confirmed the error, highlighting a deficiency in the assessment process.
Failure to Ensure Resident Dignity and Respect During CNA Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be treated with dignity and respect. The facility’s policy, “Your Resident Rights and Protections Under State and Federal Law” (dated 2022), states that residents have the right to be treated with consideration and respect in full recognition of their dignity and individuality. Resident #1, who was admitted with a diagnosis including cerebral infarction and had a BIMS score of 11 indicating moderate cognitive impairment, reported that a CNA was rude, disrespectful, always rushing, and did not provide care in a gentle manner. A Customer Concern Log and a Customer Concern/Grievance Communication Form dated 12/17/25 documented the resident’s report that the CNA was “too rough,” had a bad attitude, and did not stop the behavior despite the resident using good manners and expressing concerns. Interviews with the Administrator on 2/5/26 confirmed that CNA #1 did not provide gentle care and was rude and disrespectful to Resident #1, and that the resident’s right to dignity and respect was not honored. Progressive Discipline Forms for CNA #1 dated 12/16/25 and 12/18/25 documented continued poor work quality and productivity, including concerns from staff, residents, and family members about the CNA being too rough when handling patients, not getting patients out of bed timely, and not being present on the hallway at assigned times. Despite CNA #1 having completed Abuse, Neglect, and Exploitation training and Compliance Training on 8/31/25, as well as training on Patient/Resident Rights on 6/25/24, the facility failed to ensure that Resident #1 was consistently treated with dignity and respect during care interactions.
Failure to Complete Skills Competency Checkoffs for New Nursing Staff
Penalty
Summary
The facility failed to ensure that newly hired licensed nurses and certified nurse assistants (CNAs) received skills competency checkoffs before providing resident care. Three new hires were reviewed, and none had completed or documented skills checkoffs as required by facility policy. One graduate practical nurse reported not being assigned a preceptor, not receiving a skills checkoff form, and not having her skills reviewed before working independently. She also stated she felt overwhelmed with charting and other processes that were not reviewed with her during orientation. The Clinical Educator confirmed that she had not performed any skills checkoffs with the new nurse and was unaware if the previous Director of Nursing had done so. Additionally, the Clinical Educator acknowledged that she had never obtained completed new hire skills checkoffs since starting her role and was often pulled away from her educator duties to work on the medication cart. Review of documentation for two CNAs revealed that required skills checklists and audit tools were either unsigned, undated, or missing staff and trainer names, making it impossible to verify that competencies had been completed. The Administrator confirmed that the facility could not locate any skills review forms for the new nurse and acknowledged that all new hires should have skills checkoffs to ensure competency. The lack of completed and documented skills checkoffs for new hires resulted in the facility's failure to ensure staff competency prior to providing resident care.
Verbal Abuse by CNA Toward Resident
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) verbally threatened a resident, failing to protect the resident from verbal abuse as required by facility policy and federal and state regulations. The incident involved a cognitively intact resident who reported that the CNA shut a door in his face, refused to let him into the smoking area, and subsequently engaged in an argument with him. During the altercation, the CNA told the resident she would slap him and, when the resident threatened to call the police, stated she would put him in the morgue. The resident confirmed these statements during an interview, and another cognitively intact resident corroborated hearing the threats and the argument. A third resident also reported hearing the argument and the accusation regarding the door being closed. The facility's investigation included interviews with the involved residents and the CNA. The CNA denied making the specific threats but admitted to cursing at the resident after being cursed at. The administrator confirmed that the CNA's actions, including cursing and the threats, constituted verbal abuse according to facility policy, which defines verbal and mental abuse as conduct that can cause fear, humiliation, or intimidation. The residents involved were all cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores. The incident was substantiated based on resident interviews and the facility's internal investigation.
QAPI Program Ineffectiveness and Staff Turnover Lead to Repeated Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain and monitor the interventions implemented after the recertification survey conducted on October 19, 2023. This failure was evident during a subsequent recertification and complaint survey on February 13, 2025, where several deficiencies were re-cited, including F 584, F 656, F 677, F 684, F 761, and F 880. The facility's inability to sustain an effective QAPI program was highlighted by the recurrence of these deficiencies, indicating a pattern of non-compliance. The facility's policy on QAPI, dated February 2017, emphasizes a proactive approach to improving quality of life, care, and services, involving team members at all levels to identify and address gaps in systems or processes. Interviews with the Administrator and Director of Nursing revealed significant staff turnover, including the Infection Control Nurse/Educator, which contributed to the halting of the facility's EMBRACE rounds from November 2024 until January 2025. The EMBRACE rounds, designed to identify and correct issues, were not effectively followed up on, leading to persistent deficiencies. The Administrator acknowledged that while issues were identified during these rounds, the follow-up was insufficient to ensure correction. The Director of Nursing confirmed that identified issues were initially audited and monitored but eventually neglected, resulting in a lack of sustained corrective action.
Infection Control Deficiencies in Water Management and Equipment Storage
Penalty
Summary
The facility failed to implement adequate infection prevention and control measures, as evidenced by several deficiencies. Firstly, the facility did not have procedures in place to monitor and test the water source for Legionella's Disease, which could potentially affect all residents. During an interview, the maintenance staff revealed that while they changed shower heads and flushed unused water sources, they did not keep logs or monitor the effectiveness of these measures. The administrator confirmed the lack of documented monitoring and testing of the water system, acknowledging the potential health risks posed by Legionella and other waterborne illnesses. Additionally, the facility failed to properly store respiratory equipment for a resident with lung issues. Observations revealed that the resident's nebulizer, tubing, and mask were stored on the floor, which the Director of Nursing confirmed was unacceptable and posed a risk of respiratory infection. Despite the resident's concerns, the equipment remained improperly stored, indicating a lapse in infection control practices. The facility also did not adhere to Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices. During wound care for a resident with a chronic wound, staff failed to don gowns as required by EBP. Another resident with a PICC line did not have EBP signage, and staff did not use gowns during IV antibiotic administration. Interviews with staff revealed a lack of awareness and understanding of EBP requirements, which the Director of Nursing confirmed increased the risk of infection spread among vulnerable residents.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. Resident #8, who has Chronic Kidney Disease and requires dialysis, did not have vital signs documented before and after dialysis sessions in January 2025, as required by their care plan. The Director of Nurses confirmed the absence of these records, which were supposed to be communicated between the facility and the dialysis center. This lack of documentation indicates that the care plan for Resident #8 was not followed. Resident #11, who has multiple pressure ulcers, did not receive proper wound care as enhanced barrier precautions (EBP) were not followed during treatment. The Director of Nursing and MDS Coordinator confirmed that EBP was part of the wound care guidelines, but it was not listed as a separate intervention in the care plan. This oversight led to the care plan not being fully implemented, as EBP was not used during wound care. Other residents, including Resident #62, #74, #253, and #82, also experienced deficiencies in their care plans. Resident #62 lacked a care plan for personal hygiene, resulting in untrimmed and dirty nails. Resident #74 did not have a care plan for Activities of Daily Living (ADLs), leading to unkempt personal appearance. Resident #253's care plan for TED hose application was not implemented, as the resident was observed without the hose. Lastly, Resident #82 did not have a care plan for the proper storage of respiratory equipment, which was found improperly stored on the floor. These deficiencies highlight the facility's failure to develop and implement comprehensive care plans for its residents, impacting their overall care and well-being.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care for three residents, leading to deficiencies in maintaining their personal hygiene. Resident #62 was observed with long, dirty fingernails containing a dark brown substance, and expressed a desire to have them trimmed. The CNA confirmed the lack of nail care, and the DON acknowledged the potential for bacterial spread and skin concerns due to inadequate hygiene. Resident #62 was admitted with a diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction and was cognitively intact, requiring setup or clean-up assistance for personal hygiene. Resident #253 was observed with dirty, jagged fingernails and unkempt facial hair. The COTA confirmed the resident's nails were dirty the previous week, and the DON acknowledged the need for nail care. Resident #253 was admitted with a diagnosis of Traumatic Subdural Hemorrhage and was moderately cognitively impaired, requiring partial/moderate assistance for personal hygiene. Resident #74 was observed with long ear hair and jagged fingernails with a brown substance underneath. The Memory Care Unit Coordinator confirmed the resident's condition and noted the aides' responsibility for nail care during showers. Resident #74 was admitted with a diagnosis of Cerebral Infarction.
Failure to Provide Appropriate Treatment and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice for two residents. For Resident #253, there was a physician's order for the application of TED hose every morning and removal every night due to orthostatic blood pressures. However, observations on multiple occasions revealed that the resident was not wearing TED hose, and staff, including a CNA and an LPN, were unaware of the order or the presence of the TED hose. The lack of adherence to the physician's order could lead to increased episodes of orthostatic hypotension for the resident. For Resident #303, the facility failed to address skin concerns appropriately. Observations revealed that the resident had foam dressings on the left elbow with drainage, but there were no orders for skin treatment. A review of the resident's progress notes indicated a fall resulting in a skin tear, but there was no follow-up treatment order. An RN confirmed the lack of awareness and treatment for the skin tears, which could lead to infection or delayed healing. The facility's failure to monitor and treat the resident's skin tears according to professional standards of practice was evident.
Improper Storage of Controlled Drugs
Penalty
Summary
The facility failed to store controlled drugs in a locked, permanently affixed compartment as required by their policy. During an observation of the medication room refrigerator, an unopened box of Lorazepam Concentrate was found sitting on a shelf among other non-narcotic medications, rather than in the secure lock box designated for controlled substances. This was confirmed by an LPN who acknowledged the improper storage. The Director of Nursing also confirmed the deficiency, noting that the secure lock box was full, which may have led to the Lorazepam being placed on the refrigerator shelf. She stated that staff should have informed her of the issue, as improper storage of narcotics could lead to missing medications and potential diversion.
Facility Fails to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In Resident #48's room, two overbed tables were found with thick rust on their metal bases and torn, jagged edges, which the Director of Nursing (DON) confirmed needed replacement. Resident #48 had been admitted with diagnoses including Unspecified Dementia and Peripheral Vascular Disease. Resident #60 was observed in a wheelchair with a torn armrest and a dark-gray substance on the frame and spokes of the wheels. The resident reported using the wheelchair for three weeks in this condition. The DON confirmed the wheelchair's condition could cause a skin tear and needed cleaning. Resident #60 had a moderate cognitive impairment, as indicated by a BIMS score of 9. In room C-7, a bathroom inspection revealed a raised toilet seat with a large dried dark brown substance, identified as stool, on the seat rim and metal bar. The DON acknowledged this as an infection control concern. Additionally, Resident #99's room had a large section of missing paint behind the headboard and a rusted overbed table, which the DON confirmed did not meet the standard for a clean, comfortable, and homelike environment. Resident #99 had been admitted with diagnoses including Traumatic Subdural Hemorrhage and Dysphagia, and also had a moderate cognitive impairment with a BIMS score of 9.
Residents' Right to Smoke Restricted During Inclement Weather
Penalty
Summary
The facility failed to ensure that residents had the right to participate in smoking during rainy or inclement weather, as observed over two of the four survey days. The facility's policy prohibited staff from taking residents out to smoke during inclement weather, including rain, sleet, snow, storms, extreme heat, and freezing temperatures. This policy was enforced despite the presence of a pavilion that could provide shelter. Multiple residents, including those with nicotine dependence and cognitive impairments, expressed their desire to smoke and their dissatisfaction with the inability to do so due to the weather conditions. Staff interviews confirmed that residents were not allowed to smoke during inclement weather, and the facility's admission paperwork did not address smoking rules, leaving residents uninformed about these restrictions. Resident #60, who has a diagnosis of Major Depressive Disorder and Nicotine Dependence, expressed frustration at not being able to smoke due to the rain. Similarly, Resident #65, with a diagnosis of Heart Failure and Nicotine Dependence, and other residents voiced their concerns about missing their smoking breaks. The facility's policy and its enforcement during inclement weather led to the residents' inability to exercise their right to smoke, which they felt was important for their well-being. The facility's failure to inform residents about smoking restrictions during admission further contributed to the deficiency.
Failure to Address Personal Hygiene in Baseline Care Plan
Penalty
Summary
The facility failed to develop a thorough baseline care plan addressing personal hygiene for a resident admitted with a diagnosis of Traumatic Subdural Hemorrhage. Upon observation, the resident was found to have jagged fingernails with a dark brown substance underneath and unkempt facial hair. These observations were confirmed by a Certified Nurse Assistant and a Certified Occupational Therapist, who noted similar conditions in the past week. A review of the resident's baseline care plan, dated shortly after admission, revealed no interventions related to personal hygiene. The Director of Nursing confirmed that the care plan did not adequately address Activities of Daily Living (ADL) care, specifically personal hygiene. The resident's Admission Minimum Data Set indicated a moderate cognitive impairment, requiring partial to moderate assistance with personal hygiene, which was not reflected in the care plan.
Failure to Document and Communicate Dialysis Care
Penalty
Summary
The facility failed to provide ongoing communication documentation with the hemodialysis center for a resident receiving dialysis services. The resident, who has Chronic Kidney Disease Stage 5 and is dependent on renal dialysis, was admitted to the facility with a physician order for dialysis three times a week. However, the facility did not consistently document or transmit the necessary communication records, including pre-and post-dialysis vital signs, to the dialysis center. Interviews with the resident and staff revealed that vital signs were not always checked before and after dialysis, and communication sheets were not completed or sent to the dialysis center. The lack of communication documentation led to issues with billing for dialysis services, as noted by the MDS nurse, who stated that the facility could not bill for the dialysis services due to incomplete communication sheets. The Director of Nurses and the Administrator were unaware of the missing communication records, which were essential for coordinating care between the facility and the dialysis center. The last recorded communication with the dialysis center was in December of the previous year, indicating a lapse in the required ongoing communication for the resident's care.
Failure in Controlled Substance Accountability
Penalty
Summary
The facility failed to maintain a system of medication records that enables accurate reconciliation and accounting for all controlled medications in one of the three narcotic storage areas reviewed. During an observation of medication administration, an LPN was seen giving the medication cart keys to the Medical Records nurse to retrieve medication from the medication room. This action was against the facility's policy, which states that the medication nurse on duty should maintain possession of the keys to controlled substances. Furthermore, the LPN admitted to not checking the medication room refrigerator for narcotics during the shift change reconciliation, which was confirmed by another LPN who also failed to count the narcotics in the refrigerator. The Director of Nurses confirmed that all narcotics should be reconciled at the beginning and end of each shift to ensure an accurate account. The failure to do so could lead to missing narcotics and possible diversion. Additionally, the Medical Records nurse acknowledged that she should not have accepted the keys from the LPN, as it included access to the refrigerator narcotic box. This series of actions and inactions led to a deficiency in the facility's controlled substance accountability, as the narcotics in the refrigerator were not counted, and the keys were improperly handled.
PRN Psychotropic Medication Lacks Stop Date
Penalty
Summary
The facility failed to ensure a PRN psychotropic medication had a stop date for one of the resident's medications reviewed. Specifically, Resident #69 had an order for Ativan, an antianxiety medication, to be administered as needed for anxiety and agitation, without a stop date. This order was dated December 17, 2024, and was still active in February 2025. The resident, who was admitted to the facility in September 2021 with a diagnosis of unspecified dementia, typically received the medication on shower days due to combative behavior. An interview with a registered nurse confirmed the absence of a stop date, and the Director of Nursing explained that a stop date is necessary for the doctor to re-evaluate the need for the medication.
Failure to Honor Residents' Beverage Preferences
Penalty
Summary
The facility failed to honor the beverage preferences of two residents during dining observations. Resident #13, who was moderately cognitively impaired with a BIMS score of 10, requested a large glass of tea while dining in her room. However, RN #4 provided only a small glass of tea, citing the family's concerns about caffeine intake. The resident expressed a desire to eat in the dining room and have a large glass of tea, but her preference was not accommodated. On the following day, during lunch in the dining area, Resident #13 was again provided with only a small glass of tea. Resident #303, who was severely cognitively impaired with a BIMS score of 3 and had a medical diagnosis of acute kidney failure, requested coffee during lunch. RN #4 informed the resident that coffee was only available during breakfast, and the request was not fulfilled. The Memory Care Coordinator confirmed that residents' preferences should be honored, and the Administrator stated that coffee was available throughout the day, indicating that the staff should have provided it upon request. These actions and inactions led to the deficiency in honoring residents' beverage preferences.
Resident Restrained Without Physician's Order
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving a Certified Nurse Aide (CNA) and a resident in the Memory Care Unit. The CNA was observed standing in front of the resident, who was seated in a wheelchair, with her knee between the resident's legs, preventing the resident from standing up. The resident, who was anxious and repeatedly requested to go to the bathroom, was told by the CNA to remain seated. The Memory Care Unit Coordinator confirmed that the CNA was restricting the resident's movement to prevent a fall, as the resident had recently been toileted and was on a toileting program. The resident, who had been admitted with Alzheimer's Disease, was severely cognitively impaired and had recently experienced a decline in behavior and restlessness. The resident's frequent requests to use the bathroom coincided with a urinary tract infection for which she was receiving treatment. Interviews with the facility's Administrator, Director of Nursing, and other staff confirmed that the CNA's actions were inappropriate and constituted a restraint without a physician's order. The CNA had received training on preventing falls and dementia care, but her actions were not aligned with the facility's policy on residents' rights.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to deliver resident mail on Saturdays, affecting four residents who attended a Resident Council meeting. According to the facility's policy, residents have the right to receive their mail promptly and unopened. However, during the meeting, residents expressed that they had not been receiving their mail on Saturdays, with one resident noting that the mail remained in the mailbox until the social worker returned during the week. This issue was confirmed by the social worker, who acknowledged the importance of residents receiving their mail and admitted that the mail was left for her to distribute. The facility's administrator was unaware of the issue and stated that a manager on duty on Saturdays was responsible for distributing the mail. The administrator confirmed that mail should be distributed on days it is delivered. The residents involved were all cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores of 15, which suggests they were aware of the deficiency in mail delivery. The failure to deliver mail on Saturdays was a deviation from the facility's policy and residents' rights.
Failure to Notify Resident Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of hospital transfer to the Resident Representatives (RR) for two residents who were hospitalized. The facility's policy on transfer and discharge requires that both the resident and their RR be notified in a language and manner they understand before a transfer or discharge occurs. However, in the cases of Resident #63 and Resident #102, this procedure was not followed. Resident #63 was transferred to the hospital following a fall, and Resident #102 was transferred due to altered mental status. Despite these transfers, the required written notifications were not mailed to their RRs. Interviews with facility staff revealed a lack of awareness and communication regarding the responsibility for sending out these notifications. Social Services (SS) #1 confirmed that she did not mail the notifications and was unaware that it was her responsibility, as she had not been instructed by the previous social worker. The facility administrator confirmed that it was indeed the responsibility of Social Services to mail out hospital transfer notices and acknowledged that the notifications should have been sent to the RRs for both residents. Resident #63 had a medical diagnosis of Alzheimer's Disease, and Resident #102 had a diagnosis of Cerebral Infarction due to Unspecified Occlusion or Stenosis of the Left Cerebellar Artery.
Inaccurate MDS Medication Assessment
Penalty
Summary
The facility failed to accurately complete an assessment for the Minimum Data Set (MDS) medication section for one of the sampled residents. Specifically, an antiplatelet medication was incorrectly entered as an anticoagulant medication for a resident. The resident, who was admitted with a diagnosis of Cerebral Ischemia, had an order for Brilinta, an antiplatelet medication, which was inaccurately coded in the MDS as an anticoagulant. This error was identified during a review of the resident's quarterly MDS Section N - Medications. Interviews with the MDS Coordinator and the Director of Nursing confirmed the inaccuracy in the MDS assessment. The MDS Coordinator acknowledged the mistake and emphasized the importance of accurate MDS assessments to reflect the resident's health and abilities. The Director of Nursing also confirmed the error, stating that the MDS should accurately assess the resident's health status at a specific time. The incorrect entry of the medication type in the MDS was a clear deficiency in the facility's assessment process.
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.
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