Diversicare Of Tupelo
Inspection history, citations, penalties and survey trends for this long-term care facility in Tupelo, Mississippi.
- Location
- 2273 South Eason Boulevard, Tupelo, Mississippi 38804
- CMS Provider Number
- 255105
- Inspections on file
- 32
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Diversicare Of Tupelo during CMS and state inspections, most recent first.
A cognitively intact male resident inappropriately touched the breast of a moderately cognitively impaired female resident while both were seated together in the dining room without staff present. A dietary staff member observed the male resident stroking the female resident’s face and hair, and a CNA then witnessed the breast touching and reported it. The male resident later admitted to the touching and stated he did it because he loved her or to see her reaction, while the female resident, who had dementia and a BIMS score indicating moderate cognitive impairment, was unable to recall the incident. These events occurred despite the facility’s abuse policy stating it would take steps to prevent abuse and neglect.
A resident with hemiplegia and hemiparesis, requiring extensive two-person assistance for bed mobility and toileting, was injured after a CNA provided care alone, contrary to the Kardex instructions. The resident fell from the bed while being turned, resulting in a skin tear, facial swelling, bruising, and a maxillary hematoma, necessitating increased pain management with tramadol.
Two residents admitted from the hospital did not receive their prescribed medications on time due to delays in obtaining them from the facility's pharmacy, which was not local and did not have the required drugs in the on-site dispensing system. Staff interviews revealed that medication orders entered late in the day sometimes resulted in delayed start times, and both the DON and administrator acknowledged that the facility failed to provide timely pharmaceutical services, resulting in missed doses for antibiotics and other critical medications.
The facility failed to honor the voting rights of residents during the 2024 presidential election. Several residents expressed their desire to vote but were not provided with the necessary assistance. A resident who was unable to walk requested a mail-in ballot but did not receive one, while another was promised a ballot by staff but did not receive it. The facility's Social Services staff member acknowledged the oversight, resulting in several residents being unable to exercise their right to vote.
The facility was found deficient in several areas, including administration, resident care, medication management, and infection control. Residents reported ongoing dissatisfaction with food quality, and issues were noted with incontinent care and unauthorized medications. Unattended medication carts and inadequate implementation of Enhanced Barrier Precautions further highlighted the facility's failure to use resources effectively.
The facility's QAA committee failed to maintain and monitor interventions after a recertification survey, leading to repeated deficiencies in areas such as ADL care. Despite implementing EMBRACE rounds to identify issues, the facility struggled with follow-up and addressing root causes, resulting in a pattern of ineffective quality assurance efforts.
Two residents in a LTC facility were observed with uncovered urinary catheter bags, violating their dignity. One resident expressed embarrassment about being transported to therapy with the uncovered bag. Staff, including the ADON, RN Unit Manager, and DON, acknowledged the issue, confirming that catheter bags should be covered as per facility policy.
The facility failed to inform all residents about Resident Council meetings, limiting their participation and ability to voice grievances. Residents expressed dissatisfaction with food quality, citing issues like undercooked meals. Despite repeated complaints, grievances were not resolved, and the facility lacked a structured process to address these issues.
Two residents experienced deficiencies in their care environment. A resident had a frayed electric bed control cord with exposed wires, posing a safety hazard that had been unaddressed for over a year. Another resident's wheelchair was found dirty, with staff acknowledging the night shift's responsibility for cleaning it. Both residents were cognitively intact and had specific medical conditions requiring assistance.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with a history of nicotine dependence was found with smoking materials in his room, contrary to his care plan. Two residents with self-care deficits were observed with long, untrimmed fingernails, despite their care plans specifying regular nail care. Interviews confirmed that the care plans were not followed, resulting in inadequate care for these residents.
A facility failed to provide necessary ADL care for three residents, including nail and incontinent care. A resident was found with saturated briefs and a strong urine odor, indicating missed rounds. Two residents had long, jagged fingernails, risking infection. Staff confirmed these deficiencies, acknowledging the failure to adhere to care protocols.
The facility failed to prevent accident hazards by allowing a resident to have smoking materials in their room and another resident to self-administer medications without an order. The presence of a cigarette box in a resident's room violated the facility's smoking policy, while another resident had medications on their bedside dresser, posing a risk of double dosing. The facility relied on an honor system to manage smoking materials and was unaware of the self-administration of medications.
The facility failed to securely store medications, as observed with two medication carts. An LPN left a cart unattended with a medicine cup and bottles of magnesium, Colace, and calcium on top. The ADON confirmed this was against policy. In another instance, an RN left medication cards unsecured on a cart. Both staff members acknowledged the potential hazard of leaving medications accessible to residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) and infection control measures, affecting 11 residents. Observations showed inadequate EBP signage and staff unfamiliarity with EBP, despite prior in-service training. A CNA placed a soiled bed pad on the floor, and an LPN did not wear a gown while administering PEG tube medication, both actions posing infection risks. The number of residents on EBP increased during the survey, indicating initial under-implementation.
A resident, admitted with COPD and cognitively intact, repeatedly did not receive her preferred sweet tea with meals, despite it being listed on her meal ticket. The Dietary Manager confirmed the oversight, acknowledging the resident's right to have her preferences honored, as per facility policy.
The facility failed to ensure advance directives were properly addressed for three residents. One resident was unaware of their DNR status and wished to be a full code, another had a mismatch between their written directive and electronic records, and a third had an incomplete directive form. These issues were due to oversight and errors in handling advance directives.
A facility failed to protect resident information when a medication cart was left unattended with a visible list of resident names, room numbers, code status, and hospice or dialysis status. The ADON and DON confirmed this as a privacy violation, and the LPN responsible acknowledged the oversight. The list included details of 26 residents.
The facility failed to conduct a timely background check for a newly hired RN Unit Manager, as required by their policy. The background check was outdated, having been completed over two years before the hire date. Interviews with the Administrator, ADON, and Human Resources confirmed the oversight, acknowledging the need for an updated check to ensure no disqualifying events.
A facility failed to update a resident's care plan to include a raised perimeter air mattress used for fall prevention. Despite observations and staff interviews confirming the mattress's purpose, the care plan was not revised to reflect this intervention. The resident, diagnosed with Huntington's Disease, was admitted with specific needs that required the care plan to be updated according to facility policy.
A facility failed to administer IV antibiotics as ordered for a resident with a UTI. The MAR showed missing documentation for three days of a five-day course of Meropenem, confirmed by interviews with nursing staff. The resident, cognitively intact and dependent on renal dialysis, did not receive the full course of treatment, as confirmed by the DON.
The facility failed to assess and obtain consent for bed rails for two residents, leading to deficiencies in care. One resident with Huntington's Disease was observed with unauthorized bed rails, and the DON was unaware of their presence. Another resident with multiple health issues was found with improperly positioned bed rails, contrary to their assessment. Both cases lacked necessary consent, indicating a lapse in the facility's processes.
The facility failed to provide meals that met residents' preferences and were served in an appealing manner, affecting four residents. Complaints included repetitive, unappetizing meals, overcooked or frozen food, and lack of alternative options. Despite being aware of these issues, the Dietary Manager and Registered Dietician did not intervene, and food committee meetings ceased during the Dietary Manager's maternity leave, leaving complaints unresolved.
A resident with reduced mobility and no cognitive deficits was denied assistance with toileting by a CNA, who suggested using a brief instead. This refusal was observed by a state agency representative. Interviews with facility staff confirmed the CNA's actions were inappropriate and against the facility's policy on resident dignity.
Two residents experienced deficiencies in personal hygiene care due to the facility's failure to implement ADL care plans. One resident, with a self-care deficit, was not shaved as per her care plan, despite her request. Another resident had not received oral care since admission and lacked necessary supplies, resulting in poor oral hygiene. The DON confirmed that care plans were not followed, leading to these deficiencies.
Two residents in the facility did not receive adequate personal care, specifically in shaving and oral hygiene. One resident, with no cognitive deficits, was not shaved as per her preference, despite it being part of her care plan. Another resident, with moderate cognitive deficits, had not been provided with a toothbrush or toothpaste since admission and was not shaved regularly. The facility's policy requires care to be provided according to standards and resident preferences, but these were not met for the residents involved.
Failure to Prevent Sexual Abuse Between Residents in Dining Area
Penalty
Summary
The facility failed to protect a resident from sexual abuse when one cognitively intact male resident inappropriately touched the breast of a moderately cognitively impaired female resident. The incident occurred while both residents were seated together at a dining table without staff present in the dining room. A dietary staff member first observed the male resident stroking the female resident’s face and rubbing her hair, and then a CNA entered and directly observed him touching the female resident’s breast over her shirt. When confronted, the male resident stated he did not care if the incident was reported. Subsequent interviews and documentation showed that the male resident admitted to touching the female resident’s breast, variously explaining that he did it because he loved her, that it was what men do when they are in love, and that he wanted to see her reaction. The female resident had been admitted with unspecified dementia with mood disturbance and had a BIMS score of 11, indicating moderate cognitive impairment. During surveyor interviews, she was ambulatory but displayed a flat affect, responded only to simple questions, and was unable to consistently understand or recall the incident, stating she did not remember what had occurred. The male resident, admitted with epilepsy, anxiety disorder, and unspecified mood disorder, had a BIMS score of 15, indicating he was cognitively intact. He acknowledged being attracted to the female resident and having talked with her for a day or two before the incident, and also acknowledged being attracted to other female residents in the past, though he denied touching them. These events and conditions occurred despite the facility’s written abuse policy stating it would take appropriate steps to prevent abuse, neglect, injuries of unknown origin, and misappropriation of resident property.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
Staff failed to follow the resident's Kardex instructions requiring two-person assistance for bed mobility and toileting, resulting in a fall. On the day of the incident, a CNA was providing incontinent care to a resident with hemiplegia and hemiparesis following a cerebral infarction, who was documented as needing extensive two-person assistance for both bed mobility and toileting. The CNA attempted to turn the resident alone, during which the resident reached for the over-bed table and fell from the bed. This incident was confirmed by interviews with the CNA, other staff, the DON, and the Administrator, as well as a review of the Kardex and MDS documentation, all of which indicated the requirement for two-person assistance. As a result of the fall, the resident sustained a skin tear to the buttocks, facial swelling, bruising, and a maxillary hematoma, which led to increased pain and a new order for tramadol, an opioid analgesic. Prior to the fall, the resident had only required minimal pain management. The facility's policy required a safe environment and adherence to care plans, but staff did not follow the documented care instructions, directly resulting in the resident's injuries.
Failure to Provide Timely Pharmacy Services for Newly Admitted Residents
Penalty
Summary
The facility failed to provide timely pharmacy services to meet the medication needs of two residents following their admission from the hospital. Both residents were admitted with specific medication orders for serious conditions, including a foot infection with osteomyelitis and COPD for one resident, and seizures with pneumonia for the other. Upon review, it was found that the required medications, such as Vancomycin and Augmentin, were not administered as ordered due to delays in obtaining them from the pharmacy. The facility's medication dispensing system did not have these medications available, and the pharmacy used by the facility was not local, resulting in further delays. Interviews with staff, including an LPN and the DON, revealed that the process for entering medication orders into the facility's system sometimes resulted in start times being set for the following day if entered after a certain hour. This contributed to the missed doses, as the medications were not available in the facility and were not delivered in time for administration. The DON acknowledged that it was the nurses' responsibility to obtain information about the last dose given at the hospital and to ensure medications were administered as ordered, but this did not occur for the two residents in question. The administrator confirmed that the facility admitted residents without ensuring the immediate availability of their required medications and that pharmacy services were not able to provide the ordered medications in a timely manner. Both residents missed critical doses of their prescribed medications, and this failure was acknowledged by facility leadership as a deficiency in providing necessary pharmaceutical services.
Failure to Honor Residents' Voting Rights
Penalty
Summary
The facility failed to honor the voting rights of residents during the 2024 presidential election. Three residents, identified as #4, #5, and #6, expressed their desire to vote but were not provided with the necessary assistance to do so. Resident #6, who was unable to walk, requested a mail-in ballot but did not receive one. Resident #7 was promised a ballot by the staff but did not receive it, and Resident #8, who was registered to vote, was not taken to the polling station. The facility's Social Services staff member acknowledged the oversight, stating that she mistakenly believed that registration would automatically result in absentee ballots being mailed to the residents. This misunderstanding, coupled with a lack of timely action, resulted in several residents being unable to exercise their right to vote. The facility's policy on Resident's Rights and Quality of Life emphasizes the right of residents to a dignified existence and the ability to exercise their rights as citizens. However, the facility did not ensure that these rights were upheld, as evidenced by the failure to assist residents in voting. The administrator confirmed the facility's failure to properly assist residents in exercising their voting rights. The record review showed that out of 47 residents who desired to vote, only a small number were able to do so, with several residents not receiving the necessary support to vote either by absentee ballot or in person.
Deficiencies in Administration and Care Practices
Penalty
Summary
The facility was found to be deficient in several areas during a survey, indicating a failure to administer the facility in a manner that effectively uses its resources to ensure resident well-being. One significant issue was the lack of an Administration Policy, as confirmed by the Administrator. This deficiency was cross-referenced with multiple tags, including F 565, F 677, F 689, F 761, and F 880, highlighting various areas of concern. For instance, residents expressed dissatisfaction with the food quality during resident council meetings, and it was noted that these complaints were not consistently documented or addressed, as confirmed by the Administrator. In another instance, Resident #7 was found in a room with a strong odor of urine, indicating a lack of timely incontinent care. The resident was wearing two heavily saturated briefs, which was not in accordance with care protocols. The CNA responsible admitted to not making rounds as required, and the DON acknowledged that such neglect could increase the risk of skin breakdown. Additionally, Resident #22 was found with smoking materials in his room, contrary to facility policy, and Resident #34 had unauthorized medications, raising concerns about potential overmedication. Further deficiencies were observed in medication management and infection control practices. Unattended medication carts were found with unsecured medications, posing a risk to residents. The facility also failed to implement Enhanced Barrier Precautions (EBP) effectively, as staff were either unaware or inadequately trained on the procedures. This was evident when a nurse administered medication without donning appropriate protective gear, despite EBP signage. The Administrator admitted to a lack of follow-up on staff training and implementation of EBP, which could lead to infection control issues.
Ineffective QAA Program Leads to Repeated Deficiencies
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) committee failed to maintain and monitor the interventions they implemented following a recertification survey conducted on June 22, 2023. This failure was evident during a subsequent recertification survey on September 16, 2024, where the facility was cited for multiple deficiencies, including F 550, F 565, F 584, F 656, F 677, F 689, F 761, and F 880. The repeated deficiencies across two state surveys indicate a pattern of ineffective QAA program implementation. The facility's policy on Quality Assurance and Performance Improvement (QAPI) emphasizes a proactive approach to improving quality of life and care, involving team members at all levels to identify improvement opportunities and monitor the effectiveness of interventions. However, the facility's inability to sustain these efforts was highlighted by the recurrence of deficiencies. Interviews with the Administrator (ADM) revealed that the facility's EMBRACE rounds, intended to identify and correct issues, were not effectively addressing the root causes of deficiencies. The ADM acknowledged that while staff identified deficient practices during rounds, the follow-up was lacking. The ADM also noted that the facility's focus on daily operations and staffing led to oversight of critical details, resulting in a disconnect in monitoring and follow-up. The ADM admitted that both the floor staff and leadership, including herself and the Director of Nurses (DON), failed to consistently identify and address issues, leading to complacency when monitoring ceased.
Failure to Maintain Resident Dignity with Uncovered Catheter Bags
Penalty
Summary
The facility failed to uphold the dignity of residents by not covering urinary catheter bags, as observed in two residents. Resident #52 was seen with an uncovered urinary catheter bag containing approximately 100 cc of urine during multiple observations. The Assistant Director of Nurses confirmed that the lack of a privacy cover was a dignity issue, as per the facility's policy. Resident #52 had been admitted with diagnoses including seizures, urinary tract infection, and cognitive communication deficit, and the Minimum Data Set indicated the presence of an indwelling catheter. Similarly, Resident #190 was observed with an uncovered catheter bag containing 350 ml of urine, facing the door. The resident expressed concern about being wheeled to physical therapy with the uncovered bag, feeling embarrassed. The RN Unit Manager and the Director of Nursing acknowledged the dignity issue, agreeing that catheter bags should be covered. Resident #190, who was cognitively intact, had diagnoses including obstructive and reflux uropathy, rhabdomyolysis, and paraplegia. The Physical Therapy Assistant admitted to not paying attention to the catheter bag during transport and agreed it should be covered.
Failure to Inform Residents of Council Meetings and Address Grievances
Penalty
Summary
The facility failed to ensure that all residents were informed about the monthly Resident Council meetings, which impeded their ability to participate and voice grievances. Interviews with residents revealed that some were unaware of the meetings, with one resident stating they had never heard of them, and another attending only one meeting in three years. The Activities Director admitted that the meetings were not consistently included on the activities calendar and were sometimes only advertised via flyers in the hallway, which residents might not see. Additionally, the facility did not adequately address grievances raised during the Resident Council meetings, particularly concerning food quality. Multiple residents expressed dissatisfaction with the meals, describing issues such as undercooked or hard-to-chew food. Despite these complaints being raised repeatedly in meetings, there was no evidence of resolutions being implemented. The Social Services staff and the Administrator acknowledged that food complaints were ongoing and unresolved, with the dietary department not consistently documenting or addressing these grievances. The report highlights specific instances where residents voiced their dissatisfaction with the food, including complaints about the menu and the quality of meals served. The Dietary Manager confirmed that complaints were often related to personal preferences, but the issues persisted even after attempts to address them. The lack of a structured grievance process and the absence of a food committee during the Dietary Manager's maternity leave contributed to the ongoing dissatisfaction among residents.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by two specific incidents involving residents. Resident #12 had an electric bed control with a frayed cord and exposed wires, which posed a potential safety hazard. Despite the resident's concerns about the risk of burns or fire, the issue had persisted for over a year. Staff interviews confirmed the hazard, and a maintenance supervisor acknowledged the potential for a minor electrical shock if the wires touched. Resident #12 was cognitively intact, with a BIMS score of 15, and had been admitted with diagnoses including Type 2 Diabetes Mellitus and Chronic Kidney Disease. Resident #71's wheelchair was observed to be dirty, with a thick, grayish-dried substance and food crumbs on the base and wheel spokes. The resident expressed dissatisfaction with the cleanliness of the wheelchair. Staff interviews revealed that the night shift was responsible for cleaning wheelchairs, but the task had not been completed for Resident #71. The Assistant Director of Nurses confirmed the wheelchair's unclean state. Resident #71 was also cognitively intact, with a BIMS score of 14, and had been admitted with diagnoses including Cerebral infarction.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #22, who had a personal history of nicotine dependence, was found with a cigarette box containing a cigarette and a used cigarette butt in his room, despite his care plan stating that he should not have smoking materials on his person. This indicates that the care plan was not followed, as confirmed by the Assistant Director of Nursing. Resident #58, who had an ADL self-care performance deficit due to contractures and decreased mobility, was observed with long, jagged fingernails, despite his care plan specifying that nail care should be performed on bath days and as needed. Interviews with the resident, a CNA, and the Administrator confirmed that the care plan for nail care was not followed, as the resident's nails were not checked and trimmed as required. Similarly, Resident #59, who had a self-care deficit related to a history of CVA and decreased functional abilities, was found with long, jagged fingernails and a brown substance under some nails. His care plan included daily nail care, but interviews with the resident and the Administrator revealed that this aspect of the care plan was not adhered to, as the resident had not received the necessary assistance to maintain his nail hygiene.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) care for three residents, specifically in the areas of nail care and incontinent care. Resident #7 was observed to be lying in bed with a strong odor of urine in the room, indicating a lack of timely incontinent care. Certified Nurse Aide (CNA) #7 confirmed that the resident was incontinent and had not been checked since the start of her shift, revealing that the resident was wearing two heavily saturated incontinent briefs, which was against protocol. The Director of Nursing (DON) and the Administrator acknowledged that not providing timely incontinent care and the use of two briefs could increase the risk of skin breakdown. Resident #58 was observed to have long, jagged fingernails, which he stated were not being checked as they should be during his scheduled showers. CNA #2 confirmed the condition of the resident's nails and acknowledged that they could cause scratches and potential infections. The Assistant Director of Nursing (ADON) and the Administrator confirmed that nail care should be performed during resident baths and showers, and that the CNAs were responsible for checking nails daily. Despite the resident's cognitive intactness, he required substantial assistance with personal hygiene, which was not adequately provided. Resident #59 also had long, jagged fingernails with a brown substance underneath, and he expressed that his fingernails had not been checked in a while. CNA #2 and Registered Nurse (RN) #1 confirmed the condition of the resident's nails and the potential for infection. The resident, who had impaired vision and required assistance with personal hygiene, did not receive the necessary nail care during his scheduled baths. The facility's failure to adhere to its policy on ADL care resulted in these deficiencies, as confirmed by staff interviews and observations.
Deficiency in Preventing Accident Hazards
Penalty
Summary
The facility failed to ensure a safe environment for residents by allowing smoking paraphernalia and medications to be accessible in resident rooms. Resident #22 was found with a cigarette box containing a cigarette and a used cigarette butt in his room, despite the facility's policy prohibiting residents from keeping smoking materials. The Director of Nursing and the Administrator acknowledged that the resident could have obtained cigarettes from outside the facility and emphasized the use of an honor system to manage smoking materials. The Administrator confirmed the risk of fire due to the presence of smoking materials in the resident's room. Resident #34 was observed with bottles of Rolaids, Magnesium, and Multivitamins on his bedside dresser, which he brought from home and self-administered without an order. The Registered Nurse confirmed that the resident should not have had medication in his room, as it could lead to double dosing and medication errors. The Administrator was unaware of the resident's possession and self-administration of these medications, acknowledging the potential risk of overmedication if the resident was also receiving the same medications from the nursing staff.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely in a locked medication cart or storage room, as observed in two of the four medication carts used in the facility. During an observation, an unattended medication cart was found outside the dining room with a medicine cup full of a red liquid, a bottle of magnesium, Colace, and calcium sitting on top. The Assistant Director of Nurses confirmed that these medications should not have been left unattended, as it could lead to residents ingesting them accidentally. The Licensed Practical Nurse responsible for the cart admitted to leaving the medications unsecured while retrieving additional medication. In another instance, a Registered Nurse was observed leaving medication cards unsecured on a medication cart. The nurse placed medication cards, including Baclofen, Buspar, Augmentin, and Cyproheptadine, inside a narcotic binder but left the cart unattended with the card edges visible and accessible. Upon returning, the nurse acknowledged that leaving the medications unsecured was a hazard, as residents could have accessed them. The Director of Nurses confirmed that medications should never be left unattended on a cart.
Failure to Implement Enhanced Barrier Precautions and Infection Control Measures
Penalty
Summary
The facility failed to fully implement Enhanced Barrier Precautions (EBP) and follow infection control measures, affecting 11 residents on EBP and two specific residents. Observations revealed inadequate signage for EBP across different halls, with only a few rooms displaying the necessary signs. Interviews with staff, including CNAs, LPNs, and the RN/Infection Preventionist, indicated a lack of awareness and understanding of EBP, with some staff members having never heard of it or being unsure of its purpose. This lack of knowledge persisted despite an in-service conducted two months prior, as confirmed by the Director of Nurses and the Administrator. During the survey, it was observed that a CNA placed a soiled disposable bed pad on the floor while assisting a resident with a colostomy bag, which was acknowledged as an infection control concern by both the CNA and the Administrator. Additionally, an LPN failed to don a gown while administering medication via a PEG tube to a resident, despite the presence of an EBP sign on the door. The LPN admitted to missing the part of the in-service that covered the need for precautions with PEG medications, although the DON confirmed that staff had been in-serviced on this requirement. The facility's failure to implement EBP effectively was further highlighted by the discrepancy in the number of residents listed on EBP, which increased from four to eleven after the survey began. The Administrator acknowledged the need for auditing staff post-in-service to ensure proper implementation of EBP, which was not done, leading to the observed deficiencies.
Failure to Honor Resident's Beverage Preference
Penalty
Summary
The facility failed to honor a resident's choice for sweet tea with meals, as observed and confirmed through interviews and meal ticket reviews. Resident #44 expressed her preference for sweet tea, which had not been provided for over a month despite her requests. On two separate occasions, the resident received unsweetened tea with her meals, contrary to the meal ticket instructions that specified sweetened iced tea. The Dietary Manager confirmed that the meal ticket listed sweet tea, and acknowledged that the resident's preferences should be honored. Resident #44, who was cognitively intact with a BIMS score of 15, was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease. The facility's policy on Resident's Rights and Quality of Life emphasizes the importance of self-determination and honoring resident choices. However, the facility's failure to provide the resident with her preferred sweet tea demonstrates a lapse in adhering to this policy, as confirmed by the Dietary Manager's acknowledgment of the oversight.
Failure to Address and Update Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were properly addressed or updated for three residents, leading to discrepancies in their code status. Resident #43's advance directive indicated a Do Not Resuscitate (DNR) order, but the resident was unaware of its meaning and expressed a desire to be a full code. Interviews revealed that the resident's cognitive status had improved since admission, and he was capable of making his own medical decisions. However, the facility did not reassess or update his advance directive to reflect his current wishes until it was brought to their attention. Resident #63 initially signed a DNR order upon admission when he was very ill, but later expressed a desire to change to full code as his condition improved. Despite this, there was a mismatch between the written advance directive and the electronic system, which incorrectly listed him as a full code. This discrepancy was acknowledged by the facility staff, who admitted it was an oversight that the advance directives did not match. Resident #84's advance directive was incomplete, with only the resident's name and date of birth filled out, and lacked any indication of the resident's code status. The form was erroneously signed by a physician without being properly completed. The facility admitted that this was a careless error, as the resident's code status had not been addressed upon admission, despite the resident being cognitively intact and capable of making such decisions.
Resident Information Privacy Breach
Penalty
Summary
The facility failed to maintain the confidentiality of resident information, as observed during a survey. On one of the survey days, a medication cart was found outside the dining room door with a visible list containing resident names, room numbers, code status, and information on whether they were on hospice or dialysis. This list was accessible to anyone passing by, violating the residents' right to privacy and confidentiality as outlined in the facility's policy. The Assistant Director of Nurses (ADON) confirmed the visibility of the resident list and acknowledged it as a privacy violation. The Licensed Practical Nurse (LPN) responsible for the cart admitted to leaving the list exposed while retrieving medications, recognizing it as a privacy issue. The Director of Nurses (DON) also confirmed that the exposure of resident information was a breach of privacy. The list included details of 22 residents from the B Hall and four from the A Hall.
Failure to Conduct Timely Background Check for New Hire
Penalty
Summary
The facility failed to ensure that a new employee, specifically a Registered Nurse (RN) Unit Manager, had a current background check completed prior to employment. The facility's policy mandates that background checks must be conducted on all applicants offered employment to ensure workplace productivity, safety, and security. However, the RN Unit Manager was hired with a background check that was outdated, having been completed over two years prior to her hiring date. Interviews with the Administrator, Assistant Director of Nurses (ADON), and Human Resources confirmed the oversight, acknowledging that the background check should have been updated within two years of the hire date to ensure there were no disqualifying events or allegations against the staff member.
Failure to Update Resident Care Plan with Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised and updated, as required, for one of the sampled residents. The resident, who was admitted with a medical diagnosis including Huntington's Disease, was observed on two separate occasions lying in bed with a raised perimeter air mattress. This mattress was intended to prevent the resident from rolling out of bed. However, a review of the resident's Fall Care Plan revealed that it had not been revised to include the use of the secured perimeter air mattress. Interviews with the Director of Nursing and the Administrator confirmed that the care plan should have been updated to reflect the use of the mattress as part of the resident's fall prevention strategy. The facility's policy mandates that care plans be developed by the interdisciplinary team and revised as needed according to the resident's status or changes, which was not adhered to in this case.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to adhere to nursing standards of practice for a resident who had a physician order for intravenous (IV) antibiotics. The Medication Administration Record (MAR) for the resident indicated an order for Meropenem to be administered intravenously for five days. However, the MAR was only initialed for two days, with no documentation for the remaining three days, suggesting the medication was not administered as prescribed. Interviews with the resident and nursing staff, including the Registered Nurse (RN) Unit Manager and a Licensed Practical Nurse (LPN), confirmed the lack of documentation and administration for those days. The resident, who was admitted with a urinary tract infection and dependence on renal dialysis, was cognitively intact as per the Minimum Data Set (MDS) assessment. The Director of Nursing (DON) confirmed that without documentation, the medication was considered not given. The absence of a facility policy on Standards of Practice was noted, and the failure to administer the antibiotic as ordered could potentially worsen the resident's infection, although this was not explicitly stated in the report.
Failure to Assess and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to properly assess and obtain consent for the use of bed rails for two residents, leading to deficiencies in their care. Resident #33, who was admitted with Huntington's Disease, was observed with half side rails up on both sides of her bed, despite a clinical evaluation indicating that side rails should not be utilized. The Director of Nursing (DON) was unaware of the bed rails' presence, and the Assistant Director of Nursing (ADON) confirmed that no consent was signed for their use. The resident was on hospice care, and the bed rails were mistakenly left in place when a new bed was delivered. Resident #60, who has Type 2 Diabetes Mellitus, gait and mobility abnormalities, and a mixed receptive-expressive language disorder, was also observed with half side rails up on both sides of the bed. The Registered Nurse (RN) and DON confirmed that the bed rails were not supposed to be in that position, as the resident's assessment indicated that side rails should not be used. The Administrator acknowledged that the staff should have identified the incorrect positioning of the bed rails. Both residents' records lacked the necessary consent for the use of bed rails, highlighting a failure in the facility's assessment and consent processes.
Deficiency in Food Quality and Resident Satisfaction
Penalty
Summary
The facility failed to provide food that met the residents' preferences and served meals in an unappealing and unpalatable manner for four residents. Resident #20, who was on a renal diet, expressed dissatisfaction with the repetitive and unappetizing meals, such as a thick, gray chicken breast on a dry bun and mushy pasta salad. Despite being aware of the resident's dislikes, the Dietary Manager and Registered Dietician did not intervene to offer alternative meal options. Resident #20 was cognitively intact and had been admitted with a urinary tract infection and dependence on renal dialysis. Resident #27 reported that the food was terrible, with chicken too hard to chew and hash-browns that were still frozen inside. When requesting an alternate meal, the resident received the same meal again. The resident, who was cognitively intact and had Type 2 Diabetes Mellitus, had complained to aides but was unsure of whom else to inform. Similarly, Resident #43, who had Alzheimer's Disease, complained about the chicken being overcooked and difficult to chew, and despite multiple complaints to the cooks, no improvements were made. Resident #50 also experienced issues with food quality, receiving meals that were cold and difficult to chew, such as frozen hash-browns and overcooked chicken. The resident, who was cognitively intact and had Chronic Obstructive Pulmonary Disease, reported these issues to aides but received no resolution. The facility's Administrator and Dietary Manager acknowledged ongoing food complaints, which had not been addressed since the Dietary Manager's maternity leave, leading to a lapse in food committee meetings and unresolved resident concerns.
Failure to Assist Resident with Toileting
Penalty
Summary
The facility failed to uphold a resident's right to dignity and respect when a staff member refused to assist with toileting. During an observation and interview, a resident who was unable to walk and required assistance with toileting expressed frustration about being told by Certified Nursing Assistants (CNAs) to use her brief instead of being helped to the bathroom. The resident, who had no cognitive deficits and used a sit-to-stand lift for toileting, reported that CNAs often told her they didn't have time to assist her and suggested she use her brief instead. This incident was directly observed when a CNA refused to help the resident to the bathroom, despite the resident's request and the presence of a state agency representative. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that the CNA's actions were inappropriate and did not align with the facility's policy on resident dignity. The DON and the facility Administrator both acknowledged that refusing to assist a resident with toileting and suggesting they use their brief was unacceptable behavior. The resident's admission records indicated she had reduced mobility and required assistance with personal care, further emphasizing the need for staff to provide the necessary support when requested.
Failure to Implement ADL Care Plans for Residents
Penalty
Summary
The facility failed to implement Activities of Daily Living (ADL) care plans for two residents, leading to deficiencies in personal hygiene care. Resident #1, who had a self-care deficit related to decreased functional abilities, was observed with facial hair that had not been removed as per her care plan. Despite her expressed desire to have the facial hair removed, it was confirmed by an LPN that this task was not completed on her last bath day. The resident's care plan required extensive assistance with personal hygiene, including cueing, supervision, and assistance with ADLs, which was not adhered to. Similarly, Resident #8, who also had a self-care deficit, was found with unshaven facial hair and had not received oral care since admission. The resident expressed a need for a toothbrush and toothpaste, which had not been provided, resulting in visible white substance between his teeth and gums. The CNA assigned to him confirmed the lack of assistance with mouth care, and the LPN acknowledged the oversight in providing daily mouth care and shaving. The Director of Nursing confirmed that the care plans for both residents were not followed, as they should have been shaved on their scheduled bath days and provided with necessary oral care supplies.
Deficiencies in Personal Care for Residents
Penalty
Summary
The facility failed to provide adequate personal care for two residents, specifically in the areas of oral hygiene and shaving. Resident #1, who has no cognitive deficits and requires assistance with personal care due to reduced mobility, was observed with unwanted facial hair that had not been removed as per her preference. Despite having a care plan that included shaving during her bath on 06/10/24, the CNAs did not perform this task, as confirmed by the CNA Bath & Shower Report. Resident #8, who has moderate cognitive deficits and requires supervision for personal hygiene, was found with significant facial hair and had not been provided with a toothbrush or toothpaste since his admission over a week prior. He expressed a desire to be shaved more frequently, as he used to do at home, and had not brushed his teeth since arriving at the facility. The CNAs were responsible for providing daily mouth care and shaving during scheduled bath times, but these tasks were not completed for Resident #8, as confirmed by the CNA Bath & Shower Report and interviews with staff. The facility's policy on Activities of Daily Living (ADLs) requires that care be provided according to accepted standards and resident preferences. However, the observations and interviews revealed that the facility did not adhere to these standards for Residents #1 and #8, resulting in unmet personal care needs. The Director of Nursing confirmed that the deficiencies in shaving and oral care should have been addressed during the residents' regular bath times.
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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