Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Singing River Skilled Nursing Facility during CMS and state inspections, most recent first.
A resident with dementia and recent hip surgery was left unattended on a commode during a shift change, leading to a fall. Despite being informed, the incoming CNA did not immediately attend to the resident, who was known to be impulsive and forgetful. The facility's management acknowledged the lapse in supervision and the need for adequate oversight to prevent such incidents.
A resident with severe cognitive impairment was physically abused by a campus police officer, who struck the resident with a shoe, pushed them to the floor, and attempted to use a taser. Multiple nurses and staff witnessed the abuse but did not intervene due to fear, resulting in the resident sustaining a hematoma and requiring emergency evaluation. The staff's inaction allowed the abuse to escalate and placed other residents at risk.
Staff failed to follow a resident's behavioral care plan during an episode of agitation, instead calling a CPO who responded with physical aggression, resulting in the resident sustaining a head injury and requiring emergency evaluation. Interviews confirmed that staff did not implement the prescribed interventions, leading to harm and increased risk for others.
A resident with a documented latex allergy experienced an allergic reaction after a nurse used a latex catheter, despite the allergy being noted in the care plan. The resident, who was cognitively intact and admitted with atrial fibrillation, reported the incident, and the nurse acknowledged the oversight. The facility's policy required allergy assessments and specific interventions, but these were not effectively implemented, leading to the incident.
A resident with a known latex allergy experienced an allergic reaction after a nurse used a latex catheter due to the unavailability of non-latex alternatives. Despite being informed of the allergy, the nurse proceeded with the procedure, leading to redness, blisters, and itching. The facility's policies on allergy management were not adhered to, resulting in the nurse's termination.
The facility failed to assist and document discussions on advance directives for several residents, potentially affecting all residents. Interviews revealed that while advance directives were included in admission packets, they were not reviewed with residents or families, and no acknowledgment form was signed. Staff admitted that medical records lacked documentation related to advance directives, and the CNO was unaware of the issue.
The facility failed to provide sufficient staffing on the Northeast Hall, where residents experienced delays in assistance due to inadequate staff-to-resident ratios. Observations showed unanswered call lights and residents attempting self-transfers, leading to incontinent accidents. Staff interviews confirmed the inability to meet residents' needs promptly, with the DON acknowledging the need for more staff and an updated facility assessment.
A resident with an indwelling urinary catheter did not have a privacy cover on her drainage bag, making the urine visible to others. This was confirmed by the resident, her daughter, and a registered nurse, indicating a failure to uphold the resident's right to dignity as per the facility's policy.
The facility failed to maintain proper food storage and sanitary practices, with several food items found unlabeled or exposed, and expired products improperly stored. A Patient Services worker handled meal tickets without hand hygiene, and the Director of Food and Nutrition did not wear a beard net while handling food thermometers. These actions violated the facility's policies on food storage and hygiene.
Resident Left Unattended on Commode Resulting in Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for one of the residents. The resident, who had a history of dementia and confusion, was left unattended on a commode during a shift change. The resident had recently undergone hip surgery and was known to be impulsive and forgetful, requiring assistance for transfers. Despite these known risks, the resident was left alone, leading to a fall. The incident occurred when a CNA placed the resident on the commode and left the room to give a handoff to the incoming shift. The incoming CNA was informed that the resident was on the commode but did not immediately attend to the resident, choosing instead to obtain vital signs from other residents. During this time, the resident attempted to get up and fell, although no new injuries were sustained from the fall. Interviews with staff revealed that the resident was known to frequently attempt to get up and walk on his own, and staff were aware of his condition and the need for supervision. The facility's Operational Manager and Administrator both acknowledged that the resident should not have been left unattended, emphasizing the expectation for staff to provide adequate supervision to prevent such accidents.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A resident with severe cognitive impairment and a recent admission for acute congestive heart failure was physically abused by a campus police officer after becoming agitated and aggressive during care. The officer, called to assist by nursing staff, escalated the situation by hitting the resident with his own shoe, pushing the resident to the floor, and attempting to use a taser on the resident. The incident resulted in the resident sustaining a hematoma to the forehead, which required evaluation in the emergency department. During the incident, four nurses and other staff members were present and witnessed the abuse but failed to intervene. Multiple staff interviews confirmed that fear of the officer's aggression prevented them from assisting the resident or stopping the abuse. Surveillance footage corroborated the sequence of events, showing the officer's aggressive actions and the staff's inaction as the situation escalated. The facility's policy defined abuse as any willful act or omission resulting in physical pain, injury, or mental anguish to a vulnerable person, which includes all residents. Despite staff having received in-service training on abuse, neglect, and de-escalation, they did not act to protect the resident during the incident. The failure to intervene allowed the abuse to continue, resulting in physical harm to the resident and placing other residents at risk.
Removal Plan
- Resident was sent to the emergency room for evaluation after the incident and assessed by a nurse practitioner upon return for signs and symptoms of distress and injuries.
- Social Services conducted interviews with residents with BIMS >= 13 to determine if they feel safe from abuse at the facility.
- Police were notified of the incident and a case number was provided.
- Administrator and Director of Nursing were in-serviced on abuse and neglect.
- All SNF staff present during the patient incident were interviewed by SNF Admin.
- Nursing educator provided in-services to all SNF nursing staff prior to being allowed to work on the SNF, including abuse and neglect policy, taking immediate steps to intervene during abusive situations, dementia care, de-escalation, therapeutic communication, nurse responsibility, and abuse/neglect policies.
- Facility conducted an emergency QAPI meeting; policies were reviewed and initial monitoring of staff and patients with increased presence on the floor was implemented.
- Previous incidents were immediately reviewed to ensure abuse/neglect policy adherence and daily monitoring of incidents was continued.
- Medical Director was notified of the patient event.
- Resident's care plan was updated.
- Mississippi Board of Nursing was notified at the direction of the state agency.
- Police officer was suspended and then terminated from the facility.
- LPN, LPN, and CNA were issued a corrective action with a suspension.
- Abuse/Neglect Policy & Adherence to Care Plan will be monitored by using a minimum of 5 staff interviews per day.
- Quality of correction will also be monitored by observing interventions and interactions with patients.
- Findings will be reported to QAPI.
Failure to Implement Behavioral Care Plan Interventions Resulting in Resident Harm
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for a resident exhibiting behavioral issues. When the resident, who had a diagnosis including acute congestive heart failure, was awakened by a CNA to change soiled clothing, he became agitated and aggressive. The care plan for this resident included specific interventions such as approaching in a calm manner, diverting attention, removing the resident from the situation, giving one-step directions, allowing time to process, decreasing sudden or loud noises, and asking permission before touching or assisting. These interventions were not followed by the staff during the incident. Instead of following the prescribed care plan, a nurse called the Campus Police Officer (CPO), who responded with physical aggression. The CPO hit the resident with the resident's own shoe, pushed the resident to the ground, and attempted to use a taser. Staff present did not intervene to stop the CPO or implement the care plan interventions. As a result, the resident sustained a hematoma on the head and required emergency medical evaluation. Interviews with staff, including LPNs and the RN/Administrator on Call, confirmed that the care plan interventions were not followed during the incident. The Director of Nursing and the MDS Coordinator also stated that staff are expected to follow comprehensive, person-centered care plans to address residents' needs and safety. The failure to implement the care plan interventions directly resulted in harm to the resident and placed other residents at risk.
Removal Plan
- Resident was sent to the emergency room for evaluation after an incident involving a police officer and was assessed by nurse practitioner for signs and symptoms of distress and for injuries sustained during altercation.
- Social Services conducted interviews with residents with BIMS >= 13 to determine if they feel safe from abuse at this facility.
- Police were notified of the incident.
- Administrator and Director of Nursing were in-serviced on abuse and neglect.
- In-services were conducted by Administrative Director and LNFA Consultant.
- All SNF staff present during patient incident were interviewed by SNF Admin.
- Nursing educator provided in-services to all SNF nursing staff prior to being allowed to work on the SNF: Abuse and neglect policy, including taking immediate steps to intervene during abusive situations.
- Dementia Care, de-escalation, therapeutic communication, nurse responsibility and abuse neglect policies in-service was completed.
- Facility conducted an emergency QAPI meeting. Policies were reviewed with no changes made.
- Initial monitoring of staff and patients with increased presence on floor.
- Reviewed previous days incidents to ensure abuse/neglect policy was adhered to and continued daily monitoring of incidents.
- Medical Director was notified of patient event.
- Resident care plan updated.
- Mississippi Board of Nursing notified at the direction of state agency.
- Police officer was suspended and terminated from Singing River.
- LPN #1, LPN #2, CNA #1 were issued a corrective action with 3-day suspension.
- Abuse/Neglect Policy & Adherence to Care Plan Quality of corrections will be monitored daily by using a minimum of 5 staff interviews per day 5 days a week for 8 weeks.
- Quality of correction will also be monitored by observing interventions and interactions with patients 5 days a week for 8 weeks.
- Findings will be reported to QAPI.
Failure to Implement Care Plan for Latex Allergy
Penalty
Summary
The facility failed to implement care plan interventions for a resident with a known latex allergy, resulting in an allergic reaction. The resident, who was admitted with a history of atrial fibrillation and was cognitively intact, had a documented latex allergy since 2019, with symptoms including blisters and swelling. Despite this, a nurse used a latex catheter on the resident, leading to a topical allergic reaction. The resident and her daughter reported the incident, and the nurse involved acknowledged the allergy but proceeded with the procedure regardless. The facility's policy required that all patients be assessed for allergies upon admission, and the care plan should address these needs with specific interventions. However, the care plan for the resident noted the allergy but failed to prevent the use of latex products. The incident was confirmed by a registered nurse, who acknowledged the documentation of the allergy and the subsequent treatment for the allergic reaction. This oversight in following the care plan led to the resident experiencing an avoidable allergic reaction.
Failure to Provide Latex-Free Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with a known latex allergy, resulting in an allergic reaction. The incident involved a resident who was admitted with a history of atrial fibrillation and had a documented latex allergy since 2019. Despite the resident and her daughter informing the nurse of the latex allergy, a latex catheter was used during a procedure because the facility did not have a non-latex alternative available. This led to the resident developing redness, blisters, itching, and burning, which required treatment with an ointment approved by the Nurse Practitioner. The facility's policies on urinary catheter care and latex allergy management were not followed, as they clearly stated the need to verify allergies and use latex-free products for residents with known allergies. The nurse involved in the incident acknowledged the use of a latex catheter due to the lack of alternatives and was later placed on leave and terminated. The Nurse Practitioner confirmed the resident's allergic reaction and emphasized the potential for serious complications due to latex exposure.
Failure to Assist and Document Advance Directives
Penalty
Summary
The facility failed to offer assistance in formulating advance directives and did not document discussions related to residents' rights to establish such directives for six out of twelve residents reviewed. This deficiency potentially affects all 27 residents in the facility. The report highlights that residents were not provided with adequate information or assistance regarding advance directives during the admission process. For instance, Resident #1, who was cognitively intact, had no documentation indicating that assistance was offered. Similarly, Resident #7, with moderate cognitive impairment, also lacked documentation of any assistance or discussion about advance directives. Interviews with residents and staff revealed systemic issues in the facility's process for handling advance directives. Residents reported receiving numerous papers during admission but did not recall signing any documents related to advance directives. The Activities Director confirmed that while advance directives were included in admission packets, they were not reviewed with residents or families, and no acknowledgment form was signed. The Director of Nursing and a Registered Nurse admitted that the medical records did not contain documentation related to advance directives, and the Chief Nursing Officer was unaware of the lack of explanation and documentation regarding advance directive discussions.
Inadequate Staffing Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents in a timely manner, particularly on the Northeast Hall, where four out of nine residents were observed with unanswered call lights. The staffing plan required one nurse and one CNA for nine residents, but this proved inadequate given the residents' high acuity levels and need for assistance. During observations, call lights from multiple residents went unanswered for extended periods, leading to incidents where residents attempted to transfer themselves, resulting in incontinent accidents. Interviews with residents and their families confirmed delays in response times, with residents expressing frustration over the lack of timely assistance. Staff interviews revealed that the current staffing levels were insufficient to meet the needs of the residents, many of whom required two-person assistance for transfers. The CNA and LPN on duty confirmed that they were unable to respond to all call lights promptly due to the high demands of the residents. The Director of Nursing acknowledged the need for additional staff and admitted that the facility assessment had not been updated to reflect the current needs. The Rehabilitation Director and Chief Nursing Officer also confirmed the high acuity of the unit and the necessity for more staff to provide adequate care.
Failure to Provide Privacy Cover for Urinary Catheter
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence by not providing a privacy cover for a urinary catheter drainage bag. Resident #12, who was admitted to the facility with an indwelling urinary catheter due to acute urinary retention, did not have a privacy cover on her catheter drainage bag after it was changed. This lack of privacy cover made the urine collected in the drainage bag visible to anyone passing by, which was confirmed during an observation and interview with the resident. Further interviews revealed that Resident #12's daughter also noticed the absence of the privacy cover since the catheter bag was changed. A registered nurse confirmed the deficiency, acknowledging that the lack of a privacy cover could violate the resident's right to dignity. The facility's Patient Rights and Responsibilities Policy emphasizes the commitment to providing considerate care that respects personal values and preferences, which was not upheld in this instance.
Deficiencies in Food Storage and Sanitary Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitary practices, as observed during a kitchen inspection. Several food items in refrigerators and freezers were found without proper labeling or dates, making it unclear when they were received or should be used by. Some foods were exposed, such as an opened bag of lettuce and a fresh pineapple with the core removed. Additionally, there were expired and damaged products, like milk, stored improperly. In the dry storage area, bins of rice and chicken batter were left open, and a bag of breadcrumbs was exposed, attracting insects. These observations indicate a lack of compliance with the facility's policy on food and supply storage, which requires items to be covered, labeled, and dated to prevent contamination. Sanitary practices were also compromised, as evidenced by a Patient Services worker who picked up meal tickets from the floor and placed them on residents' trays without performing hand hygiene. The Director of Food and Nutrition was observed handling food thermometers without wearing a beard net, which is against the facility's hygiene policy. The Director acknowledged these deficiencies, including the unclear labeling of food items, and confirmed that the date labels were meant to indicate the date of receipt, which could be confusing for new employees. The Hospital Administrator was informed of these issues and expressed an expectation that no expired foods should be present in the kitchen.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Plaza Community Living Center | 0.2 mi | ★★★★★ | 1 | 0 |
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| River Chase Village | 7.7 mi | ★★★★★ | 0 | 0 |
| Sunplex Sub-acute Center | 11.6 mi | ★★★★★ | 15 | 6 |
| Ocean Springs Health & Rehabilitation Center | 12.2 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.