Diversicare Of Ripley
Inspection history, citations, penalties and survey trends for this long-term care facility in Ripley, Mississippi.
- Location
- 101 Cunningham Dr, Ripley, Mississippi 38663
- CMS Provider Number
- 255102
- Inspections on file
- 25
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Diversicare Of Ripley during CMS and state inspections, most recent first.
The facility failed to provide adequate dietary staffing, resulting in residents receiving cold and unpalatable meals. Observations and interviews revealed that the kitchen was consistently short-staffed, leading to delays in meal service and poor food quality. Residents reported receiving improperly cooked meals, with overcooked meats and mushy vegetables, and expressed dissatisfaction with the limited food choices. The lack of insulated boxes and a steamer in the kitchen further contributed to the issues with meal temperature and quality.
The facility failed to provide palatable and properly heated meals to residents, with reports of cold, overcooked, and unappetizing food. Staffing shortages and lack of proper equipment in the dietary department contributed to the issue, affecting eight out of twelve sampled residents.
The facility was found to have unsafe food handling practices, including thawing meat at room temperature and improper disposal of raw chicken skin, which could lead to foodborne illness. Dietary staff confirmed these practices were against policy, and the Regional Dietary Manager acknowledged the potential for illness.
The facility failed to accurately report staffing data in the PBJ system for the fourth quarter of 2024, leading to a deficiency for low weekend staffing. Manual entry errors and delayed updates contributed to the inaccuracies, as confirmed by interviews with the Workforce Management Coordinator, Human Resource Coordinator, and Administrator. Verification showed that additional staff were present and providing care, but not recorded in the system.
The facility failed to implement care plans for several residents, leading to deficiencies in their care. A resident with a self-care deficit had unkempt nails and facial hair, while another with severe cognitive deficits had dirty fingernails. A third resident reported not receiving scheduled showers, resulting in greasy hair and odor. Additionally, a resident with respiratory issues did not have their oxygen tubing and humidifier bottles changed as required, posing a risk of infection.
The facility failed to provide necessary ADL assistance for three residents, leading to deficiencies in personal care. A resident had long, dirty fingernails and an unkempt beard, despite being cognitively intact and expressing a desire for care. Another resident had dirty fingernails and required a two-person assist with ADLs, while a third resident missed scheduled showers, resulting in greasy hair and body odor. Staff confirmed these deficiencies, and the residents' cognitive and physical conditions were noted.
The facility failed to maintain the dignity of three residents by not covering their urinary catheter bags and tubing, as required by policy. A resident with severe cognitive deficits was observed with an uncovered catheter bag visible from the hallway. Another resident with moderate cognitive deficits expressed discomfort with his exposed catheter bag. A third resident, cognitively intact, was observed with an exposed catheter bag containing a brown substance. Staff confirmed that the catheter bags should have been covered to uphold the residents' dignity.
A facility failed to change a resident's oxygen tubing and humidifier water bottle as ordered, with observations showing the equipment was not updated since 11/29. Staff interviews confirmed the oversight, and the DON acknowledged the failure to follow the physician's order. The resident, with respiratory conditions, was cognitively intact.
The facility failed to provide adequate nursing staff to meet the ADL needs of three residents. A resident with cognitive deficits had unclean fingernails, while another resident missed scheduled baths due to staff being too busy. The DON confirmed ongoing staffing issues, particularly on the 3 PM-11 PM shift, with frequent call-ins leading to understaffing. Despite offering incentives and having nurses assist, the facility struggled to provide necessary care.
A resident's medications, including inhalers and a nebulizer, were found unsecured on a bedside table, contrary to facility policy requiring locked storage. The resident, cognitively intact, stated the inhalers were for emergencies. An LPN and the DON confirmed the medications should have been secured, highlighting a lapse in adherence to medication storage protocols.
Two residents in an LTC facility experienced deficiencies in dining services. One resident was denied alternative food items until all residents were served, despite staff claims of sufficient food availability. Another resident's preference for sausage over bacon was not honored due to a computer glitch, leading to repeated receipt of food she could not eat. The Dietary Manager acknowledged the issues but failed to resolve them adequately.
The facility failed to properly contain and dispose of kitchen trash, as observed during a kitchen tour. Two trash barrels were found overflowing and uncovered, with empty boxes stacked on top. Dietary staff confirmed the unsanitary condition, citing a lack of time due to shift change and meal preparation. The Regional Dietary Manager confirmed that trash should be emptied once per shift and as needed, with lids intact for safe disposal.
A resident in an LTC facility suffered a fall and fracture due to the use of an incorrect sling during a transfer. The care plan specified an extra-large blue sling, but two CNAs used a green sling, which was not suitable for the resident's weight. The CNAs did not check the care plan or Kardex, leading to the incident.
A resident in an LTC facility fell and sustained fractures during a lift transfer due to the use of an inappropriate sling. The staff used a green sling instead of the care-planned blue sling for bariatric residents, leading to a strap breaking and the resident falling. The resident, who was morbidly obese and cognitively intact, required surgery for a femur fracture. Staff interviews revealed a lack of awareness regarding the correct sling to use, contributing to the incident.
The facility failed to provide palatable and properly prepared meals, as evidenced by multiple resident complaints and staff confirmations. Residents reported that food was often hard, overcooked, and difficult to chew, with issues noted with pancakes, meat, and bread. Staff acknowledged these problems, attributing them to overcooking and prolonged steam table exposure. Despite a new District Dietary Manager, the facility did not meet its policy standards for nourishing and attractive meals.
Inadequate Dietary Staffing Leads to Cold and Unpalatable Meals
Penalty
Summary
The facility failed to ensure sufficient staffing in the dietary department, which resulted in the inability to meet the nutritional needs of residents. Observations and interviews revealed that the facility did not employ adequate dietary staff to prepare and serve meals in a timely manner, leading to residents receiving cold meals and experiencing prolonged delays during meal service. The Regional Dietary Manager (RDM) confirmed the ongoing staffing issues, noting that the kitchen was consistently short-staffed, and he had to assist in meal preparation himself. Additionally, the facility's Administrator acknowledged the staffing challenges and expressed concerns about the frequent changes in dietary management. Multiple residents expressed dissatisfaction with the quality and temperature of the food served. Residents reported receiving meals that were cold, improperly cooked, and unpalatable. Specific complaints included overcooked meats, mushy vegetables, and limited food choices. Observations confirmed that meal trays were placed on uncovered tray racks, contributing to the food cooling before reaching the residents. The new RDM noted the absence of a steamer in the kitchen, which affected the quality of cooked vegetables, and highlighted the lack of insulated boxes for maintaining food temperature during distribution. The report included detailed accounts from several residents, all of whom were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores. These residents had various medical diagnoses, including Chronic Obstructive Pulmonary Disease, Dysphasia, Type 2 Diabetes Mellitus, and Acute Chronic Diastolic Heart Failure. Despite their medical conditions, the residents consistently reported issues with the food service, emphasizing the facility's failure to provide meals that met their nutritional and dietary needs.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. This deficiency was observed in eight out of twelve sampled residents. The facility's policy on food quality and palatability, revised in February 2023, mandates that food should be prepared in a manner that conserves nutritive value, flavor, and appearance, and should be served at a safe and appetizing temperature. However, multiple residents reported that the food was often cold, overcooked, or undercooked, and lacked flavor and appeal. Interviews with residents revealed significant dissatisfaction with the food quality. One resident reported eating grilled cheese and soup daily due to the unpalatability of the menu items, while another described the food as not fit to eat, citing issues with overcooked and mushy vegetables and tough meat. Several residents mentioned that the food was consistently cold, with one resident stating that it was as if the food had been in the refrigerator. Observations confirmed that meal trays were left uncovered on tray racks, contributing to the food being served cold. The facility's dietary department faced staffing challenges, as noted by the Regional Dietary Manager, who highlighted ongoing staff shortages and transitions within the department. The Administrator acknowledged awareness of the dietary concerns and mentioned efforts to address them, although the issues persisted. The new Regional Dietary Manager observed that the kitchen lacked a steamer, which contributed to the poor texture of vegetables. The absence of insulated boxes for tray distribution was also identified as a factor in the food being served cold.
Unsafe Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to safe food handling practices, which could lead to the spread of foodborne illness. During a kitchen tour, it was observed that five packs of kielbasa sausages were left to thaw at room temperature in a two-compartment sink without running water. This practice contradicts the facility's policy, which requires thawing frozen items in a refrigerator or under cold running water to prevent bacterial growth. Dietary Staff confirmed that the meat should not have been left out at room temperature, acknowledging the potential for bacteria growth. Additionally, a brown box containing raw chicken skin was found on the kitchen floor, with the skin resting on the outer edges of the box. The box was observed to drip pink-tinged watery drainage onto the floor and the drainboard of the sink. Dietary Staff admitted that the chicken skin should have been disposed of in the garbage during preparation to prevent contamination. The Regional Dietary Manager confirmed these unsafe practices and acknowledged that they could lead to illness.
Inaccurate PBJ Submissions Lead to Staffing Deficiency
Penalty
Summary
The facility failed to submit accurate data into the Payroll Based Journal (PBJ) system for one of the four quarters reviewed, specifically the fourth quarter of 2024. The facility's policy on PBJ entry submission, dated 2022, requires collaboration with Human Resources and Payroll to capture payroll hours for clinical team members and submit them accurately. However, interviews with the Workforce Management Coordinator and the Human Resource Coordinator revealed discrepancies in the reporting process. The Workforce Management Coordinator admitted that salary employees who worked weekends had their hours entered manually, which she believed led to inaccuracies. The Human Resource Coordinator confirmed that staff schedule changes were typically entered into the system on Monday or Tuesday after the weekend, which could result in inaccurate reports if submitted before these updates. The Administrator acknowledged the issue, noting that the PBJ submissions were sent to corporate staff on Monday mornings, and if weekend changes were not entered by then, the data was inaccurate. This resulted in the facility being flagged for low weekend staffing. A review of the facility's staffing validation computer printout confirmed that additional staff who worked were not entered into the system. Verification by the State Agency showed that these staff members were present and providing resident care, further highlighting the inaccuracies in the PBJ submissions.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for several residents, leading to deficiencies in their care. Resident #8, who was admitted with a need for assistance with personal care and a contracture in the left hand, had a care plan that included daily nail, hair, and oral care. However, observations revealed that his fingernails were long and dirty, and his facial hair was unkempt. Despite expressing a desire for grooming, the care plan interventions were not followed, as confirmed by the MDS nurse. Resident #58, who had severe cognitive deficits and was admitted with hemiplegia and hemiparesis, also had a care plan for daily nail, hair, and oral care. Observations showed that his fingernails were dirty with a brown substance underneath, and this was confirmed by a CNA. The MDS Coordinator acknowledged that the care plan was not adhered to, as the resident's nails remained unclean. Resident #104, who was cognitively intact and had a self-care deficit, reported not receiving scheduled showers and hair care, resulting in greasy hair and a mild odor. The MDS Coordinator confirmed that the care plan, which included assistance with bathing and daily grooming, was not followed. Additionally, Resident #73, who had respiratory issues, had a care plan requiring weekly changes of oxygen tubing and humidifier bottles. Observations revealed that these were not changed as ordered, and the DON confirmed the care plan was not followed, posing a risk of infection.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for three residents, leading to deficiencies in personal care. Resident #8 was observed with long, jagged fingernails with a thick brown substance underneath and an unkempt beard. Despite expressing a desire for nail and beard care, there was no documentation of recent refusals of ADL care, and the Director of Nursing confirmed that the resident should have received these services. Resident #8 was cognitively intact, as indicated by a BIMS score of 15, and had a diagnosis requiring assistance with personal care. Resident #58 was observed with a brown substance under the fingernails of his right hand on multiple occasions. CNA #5 confirmed the presence of dirt and acknowledged the responsibility to clean residents' nails during baths or showers. Resident #58 required a two-person assist with ADLs and had severe cognitive deficits, as indicated by a BIMS score of 4. His diagnoses included hemiplegia and hemiparesis following a cerebral infarction, aphasia, and chronic obstructive pulmonary disease. Resident #104 reported not having received a shower since a specific date, resulting in greasy hair and body odor. CNA #5 confirmed that Resident #104 missed a scheduled shower and should have received one to maintain cleanliness and prevent odor. The Assistant Director of Nursing verified that Resident #104's hair was oily and that she should have received her scheduled shower. Resident #104 was cognitively intact, with a BIMS score of 15, and had diagnoses including difficulty in walking and a need for assistance with personal care.
Failure to Maintain Resident Dignity by Not Covering Catheter Bags
Penalty
Summary
The facility failed to uphold the dignity of three residents by not covering their indwelling urinary catheter bags and tubing, as required by the facility's policy. Resident #58 was observed with a catheter bag containing urine visible from the hallway without a privacy bag. Interviews with CNA #5 and the Assistant Director of Nursing confirmed that the catheter bag should have been covered to maintain the resident's dignity. Resident #58 had severe cognitive deficits, as indicated by a BIMS score of 04. Resident #99 was seen with a catheter bag attached to his wheelchair, visible from the hallway, and not covered by a privacy bag. The resident expressed discomfort with the exposure of his catheter bag. CNA #6 and the Assistant Director of Nursing confirmed that the catheter bag should have been covered. Resident #99 had moderate cognitive deficits, with a BIMS score of 11. Resident #103 was observed with an exposed catheter bag containing a brown substance, which the resident found unpleasant. LPN #1 and the Director of Nurses confirmed that the catheter bag should have been covered to respect the resident's dignity. Resident #103 was cognitively intact, with a BIMS score of 15.
Failure to Change Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing and an oxygen concentrator humidifier water bottle were changed as ordered for a resident. The facility's policy, updated on 8/1/2024, requires that oxygen with humidification be provided according to a physician's order. For Resident #73, the order dated 12/6/24 specified that the oxygen tubing and humidifier bottle should be changed weekly, and external filters should be cleansed every Friday. However, observations on 12/15/24 and 12/16/24 revealed that the oxygen tubing was dated 11/29, and the humidifier water bottle was empty and undated, indicating that the facility did not follow the physician's order. Interviews with staff, including an LPN and the DON, confirmed that the nightshift nurses were responsible for changing the oxygen tubing and humidifier bottles weekly. The DON acknowledged that the facility failed to follow the physician's order, as the tubing and humidifier bottle had not been changed since 11/29. The resident involved, who was admitted with medical diagnoses including Acute Respiratory Failure with Hypoxia, Unspecified Asthma, and Chronic Obstructive Pulmonary Disease, had a BIMS score of 15, indicating cognitive intactness. The failure to change the equipment as ordered was recognized as important to prevent potential infections.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the activities of daily living (ADL) needs of three residents. Resident #8, who was cognitively intact, had long, jagged fingernails with a thick brown substance underneath and an unkempt beard. He expressed a desire for personal grooming but reported that no one was available to assist him. Certified Nurse Assistant (CNA) #4 confirmed the resident's condition and attributed the lack of care to staffing shortages. Resident #58, who had severe cognitive deficits, was observed with a brown substance under his fingernails on multiple occasions. CNA #5 acknowledged the responsibility to clean the resident's nails during bathing but cited staffing issues as a barrier to providing adequate care. Resident #104, also cognitively intact, reported missing scheduled baths due to staff being too busy. Her hair was greasy, and she noted an odor, indicating a lack of personal hygiene care. CNA #5 confirmed that Resident #104's hair should have been washed on her scheduled bath days but was not. The Director of Nursing (DON) acknowledged ongoing staffing concerns, particularly on the 3 PM-11 PM shift, with frequent call-ins leading to understaffing. The facility attempted to mitigate this by offering incentives and having nurses assist with care, but the issue persisted, affecting the quality of care provided to residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored appropriately, as evidenced by the observation of two inhalers and a nebulizer machine with unopened medication packages left on the bedside table of a resident. The resident, who was cognitively intact with a BIMS score of 15, stated that the inhalers were for emergency use. However, the medications were not secured in a locked compartment as required, which was confirmed by both an LPN and the Director of Nurses. The LPN acknowledged that the medications should have been returned to the medication cart, and the DON emphasized the risk of wandering residents accessing unsecured medications. The resident involved had been admitted to the facility with medical diagnoses including Chronic Respiratory Failure, Pulmonary Fibrosis, and Atelectasis. Despite the resident's cognitive intactness, the facility's lack of a specific policy for medication storage contributed to the oversight. The facility relied on medication administration competencies and standards of practice, which were not adequately followed in this instance, leading to the deficiency.
Failure to Provide Alternative Food Items and Honor Preferences
Penalty
Summary
The facility failed to provide alternative food items and honor food preferences for two residents, leading to deficiencies in dining services. Resident #59 expressed dissatisfaction with the food, stating that requests for alternative items were denied until all residents were served, due to concerns about food shortages. This was confirmed by multiple staff interviews, including a CNA and the Dietary Manager, who indicated that the practice was to ensure all residents were served before providing additional servings or alternatives. The District Dietary Manager contradicted this practice, stating there was always enough food and alternatives available. Resident #83 experienced a failure in honoring her food preferences due to a computer system glitch. Despite expressing her preference for sausage over bacon due to her inability to chew bacon without bottom dentures, she continued to receive bacon. The Dietary Manager acknowledged the issue, noting that the meal ticket incorrectly listed bacon as a preference, despite having been updated in the system. The Dietary Manager admitted to not following up adequately to resolve the issue, resulting in the resident repeatedly receiving food she could not eat.
Improper Disposal of Kitchen Trash
Penalty
Summary
The facility failed to properly contain and dispose of kitchen trash during a kitchen tour. The facility's policy requires that all garbage and refuse be collected and disposed of safely and efficiently, with the dining service director ensuring that garbage is removed from the kitchen routinely and at the end of the workday. During an observation on 12/15/24, two trash barrels in the kitchen were found to be full, overflowing, and uncovered, with multiple empty boxes stacked on top. Dietary Staff #1 confirmed the unsanitary condition, attributing it to a lack of time to empty the garbage due to a shift change and dinner meal preparation. The Regional Dietary Manager later confirmed that kitchen trash should be emptied once per shift and as needed, with lids remaining intact to ensure safe waste disposal.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who required assistance with transfers due to a physical functioning deficit. The care plan specified the use of a total lift with an extra-large blue sling, appropriate for the resident's weight of 376.3 pounds. However, during a transfer, two CNAs used a green sling, which was not suitable for the resident's weight, leading to the sling breaking and the resident falling to the floor, resulting in a fracture. The incident occurred when the CNAs, who were responsible for transferring the resident from her bed to a wheelchair, used the wrong sling. They admitted to using the green sling because it was the one they had always used, without checking the care plan or the Kardex for the correct sling size. The CNAs were unaware that the care plan specified the use of the extra-large blue sling, which was necessary due to the resident's weight and physical condition. The MDS Coordinator confirmed that the care plan was not followed, which directly led to the resident's fall and injury. The facility's policy required that care plans be developed and maintained according to RAI guidelines, but this was not adhered to in this case. The failure to follow the care plan and use the correct equipment resulted in a significant injury to the resident.
Removal Plan
- Resident #1 was assessed by Nurse Practitioner immediately after the fall and was sent out to the emergency room.
- Lift was inspected following the incident with no identified concerns by Maintenance.
- The lift and sling involved in the accident were removed from the floor by Administrator and remained out of service immediately.
- All lifts and slings were assessed for any disrepair by Administrator and four yellow slings, one blue sling and one green sling were removed due to being worn, and in ill repair. New replacements were ordered.
- New lift slings arrived, they were numbered, dated, and put in service.
- The Kardex was reviewed for all residents for appropriate lift and sling use by the Director of Clinical Education (DCE).
- CNA #1 and CNA #2 were educated on proper lift and sling use and return demonstration was completed by the DCE.
- Checkoffs were completed by the DCE with all staff which were initiated and continue throughout all shifts until everyone completed.
- New Lift Transfer assessments were completed by the ADON on all current residents and care plans were updated.
- Therapy referrals were made as needed by the ADON for anyone who required a lift and lift sling.
- Care Plans and Kardex updated as needed by the ADON.
- Team huddles with lift/transfer education completed by the DCE.
- State Agency, Ombudsman, and Attorney General (AG's) office notified by Director of Nursing.
- In-Service on Lift/Transfer Program and Transfer Belts, Abuse/Neglect/Exploitation, and Elder Justice Program were completed by the DCE for all staff members with 100% compliance.
- Topics included: Performance of lift usage, inspecting the sling prior to use, laundering slings and where to find them, and on the Kardex - only using care planned sling colors.
- In-Services initiated with Housekeeping and Laundry Manager on sling inspection and guidelines by the DCE.
- Hoyer Lift Policy and Procedures were reviewed with CNA #1 and CNA #2 and all other staff by the DCE.
- Audits on all Lift Assessments were completed and are on-going by the ADON.
- Quality Assurance and Performance Improvement (QAPI) meeting was held and all required staff members were in attendance. Plan to continue the weekly audits and bring results to the monthly QAPI meetings for three months.
Inappropriate Sling Use Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a dependent resident during a lift transfer, resulting in a fall and subsequent injuries. The incident involved the use of an inappropriate lift sling for a resident who was morbidly obese. The staff used a green sling, which was not suitable for the resident's weight, instead of the care-planned blue sling designed for bariatric use. During the transfer from bed to wheelchair, the right shoulder strap of the green sling broke, causing the resident to fall to the floor and sustain fractures. The resident, who was cognitively intact and required assistance with personal care due to severe obesity, experienced a traumatic fall. The fall was witnessed by two CNAs who were performing the transfer. The resident landed on her right side, hitting her head and complaining of pain in her right shoulder and left hip. Emergency medical services were called, and the resident was transported to the hospital, where she underwent surgery for a comminuted mildly displaced left intertrochanteric femur fracture. Interviews with staff revealed that the CNAs were unaware of the correct sling to use, as they had always used the green sling for this resident. The facility's policy required the use of appropriate slings based on lift evaluations, but this was not adhered to. The CNAs admitted to not checking the care plan or Kardex for the correct sling, leading to the use of an unsuitable sling that could not support the resident's weight, ultimately resulting in the fall and injury.
Removal Plan
- Resident #1 was assessed by Nurse Practitioner immediately after the fall and was sent out to the emergency room.
- Lift was inspected following the incident with no identified concerns by Maintenance.
- The lift and sling involved in the accident were removed from the floor by Administrator and remained out of service immediately.
- All lifts and slings were assessed for any disrepair by Administrator and four yellow slings, one blue sling and one green sling were removed due to being worn, and in ill repair. New replacements were ordered. New lift slings arrived, they were numbered, dated, and put in service.
- The Kardex was reviewed for all residents for appropriate lift and sling use by the DCE.
- CNA #1 and CNA #2 were educated on proper lift and sling use and return demonstration was completed by the DCE.
- Checkoffs were completed by the DCE with all staff which were initiated and continue throughout all shifts until everyone completed.
- New Lift Transfer assessments were completed by the ADON on all current residents and care plans were updated.
- Therapy referrals were made as needed by the ADON for anyone who required a lift and lift sling.
- Care Plans and Kardex updated as needed by the ADON.
- Team huddles with lift/transfer education completed by the DCE.
- State Agency, Ombudsman, and Attorney General (AG's) office notified by Director of Nursing.
- In-Service on Lift/Transfer Program and Transfer Belts, Abuse/Neglect/Exploitation, and Elder Justice Program were completed by the DCE for all staff members with 100% compliance.
- Topics included: Performance of lift usage, inspecting the sling prior to use, laundering slings and where to find them, and on the Kardex - only using care planned sling colors.
- In-Services initiated with Housekeeping and Laundry Manager on sling inspection and guidelines by the DCE.
- Hoyer Lift Policy and Procedures were reviewed with CNA #1 and CNA #2 and all other staff by the DCE.
- Audits on all Lift Assessments were completed and are on-going by the ADON.
- Quality Assurance and Performance Improvement (QAPI) meeting was held and all required staff members were in attendance. Plan to continue the weekly audits and bring results to the monthly QAPI meetings for three months.
Deficiency in Meal Quality and Palatability
Penalty
Summary
The facility failed to provide palatable and properly prepared meals to its residents, as evidenced by multiple complaints and observations. Residents reported that the food was often hard, overcooked, and difficult to chew, with specific issues noted with pancakes, meat, and bread. For instance, Resident #2 and Resident #3 both reported that their pancakes were too hard to cut and eat, and Resident #5, who is the Resident Council President, mentioned that she often did not eat the food because it was not appetizing. Staff members, including a Registered Nurse and a Certified Occupational Therapy Assistant, confirmed the residents' complaints, noting that the food was often too tough and hard to chew, particularly for residents with dentures or no teeth. The District Dietary Manager acknowledged the issues with the food, attributing some of the problems to overcooking and leaving food on the steam table for too long. The Social Worker also confirmed that there had been numerous complaints about the food being cold and tough, and that the facility had experienced significant staff turnover in the dietary department. The report highlights that the facility's policy requires meals to be nourishing, palatable, and attractive, yet the observations and interviews indicate a failure to meet these standards. Residents with specific dietary needs, such as those with dysphagia, were particularly affected by the poor quality of the meals. Despite the presence of a new District Dietary Manager, the issues with meal preparation and palatability persisted, impacting the residents' satisfaction and nutritional intake.
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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