The Pillars Of Biloxi
Inspection history, citations, penalties and survey trends for this long-term care facility in Biloxi, Mississippi.
- Location
- 2279 Atkinson Road, Biloxi, Mississippi 39531
- CMS Provider Number
- 255093
- Inspections on file
- 33
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at The Pillars Of Biloxi during CMS and state inspections, most recent first.
Two residents did not receive medications in accordance with physician orders and professional standards. One resident with lumbar disc degeneration and moderately impaired cognition continued to receive a discontinued narcotic (Hydrocodone-APAP) for several days after a new opioid (Oxycodone-APAP) was ordered and delivered, because both drugs remained active on the MAR and an RN administered both without questioning the duplicate opioid therapy. Another resident, comatose with anoxic brain damage and a PEG tube, returned from the hospital with orders to start nitrofurantoin (Macrobid) for a UTI, but the antibiotic was not transcribed and administered until five days later, despite the hospital discharge documentation specifying it should be started upon return.
A GPN continued to function as an LPN for several days after receiving notice of failing the NCLEX-PN, contrary to state Board of Nursing rules that invalidate a temporary permit upon exam failure. Time cards, staffing schedules, and assignment sheets showed the GPN worked full shifts with full resident assignments, administering meds, performing treatments, and documenting in medical records while unlicensed. The GPN did not notify facility administration of the failed exam or verify permit status, and the DON, unaware of the failure, relied on the nurse to self-report results and had no system in place to confirm exam outcomes with the Board of Nursing.
A resident was prescribed multiple antipsychotic medications, including Olanzapine and Haloperidol, for indications such as mood and psychosis, despite medical records only documenting depression and no other psychiatric or mood disorders. Staff interviews revealed that the pharmacist and nursing staff relied on general processes for associating diagnoses with medication orders, but the documentation did not support the clinical need for these antipsychotic prescriptions.
A resident with moderate cognitive impairment exited the facility unnoticed by pushing out a window screen and leaving through his room window. The resident, not previously identified as an elopement risk, was last seen by a CNA and later found outside by staff, wearing only shorts and no shoes. The facility's lack of adequate supervision and insufficient environmental safeguards on windows resulted in the resident leaving the building undetected.
A resident with a self-care deficit and hemiplegia fell and sustained a fracture due to a CNA not using the required sit-to-stand lift during a transfer. The CNA attempted a manual transfer because the lift's battery was uncharged, leading to the resident slipping and falling.
A resident identified as a fall risk sustained a mildly displaced fracture of the proximal right humerus after a CNA failed to use the prescribed sit-to-stand lift during a transfer. The resident's foot slipped, causing her to fall onto the CNA, who attempted to break the fall. The resident, with a history of hemiplegia and hemiparesis, was sent to the hospital for evaluation and treatment.
A resident identified as an elopement risk due to impaired safety awareness and wandering behavior exited the facility unsupervised. Despite being escorted to the therapy gym, the resident was later found missing and discovered one mile away. The care plan interventions to prevent wandering were not effectively implemented, as confirmed by interviews with facility staff.
A resident identified as an elopement risk exited a facility unsupervised, following another person out through a frequently used rehabilitation door. Despite being recognized as a wandering risk, the resident was left unattended in the therapy gym and was found a mile away. The facility's failure to implement effective supervision and monitoring led to this incident.
The facility failed to store food according to professional standards, with undated and unlabeled food items found in the kitchen, including expired thickened lemon-flavored water and overly ripe bananas. The CDM and DAS confirmed the responsibility for labeling and inventorying food items, and the Administrator acknowledged a lapse in protocol.
The facility failed to resolve resident council concerns related to housekeeping, laundry, and dietary issues over six months. Despite policy requirements, grievances were not reviewed or resolved in a timely manner, leading to resident dissatisfaction.
The facility failed to ensure a clean and comfortable environment for its residents, as evidenced by soiled privacy curtains in the rooms of two residents. Housekeeping staff are expected to check curtains daily, but this was not done, and the Administrator was unaware of the issue.
The facility failed to date a multi-use medication vial and improperly stored medications, food, and biohazard substances together in two medication rooms. Nurses were responsible for dating vials and discarding expired medications, but an undated vial was found. Additionally, a biohazard refrigerator contained food items and blood vials, posing a contamination risk.
The facility's QAPI Committee failed to sustain its program during leadership transitions, resulting in repeated deficiencies related to residents' rights/environment and investigations. The facility did not ensure a clean environment for two residents and failed to complete a thorough investigation regarding an injury of unknown origin for one resident.
A facility failed to thoroughly investigate an injury of unknown origin for a resident with bilateral pubic ramus fractures. The investigation did not include interviews with other nearby residents or external parties involved in the resident's care, leading to an incomplete understanding of how the injury occurred.
The facility failed to provide written notification of facility-initiated transfers to residents or their Resident Representatives (RR) for five residents. While phone notifications were made, written notifications were not consistently provided, as confirmed by staff interviews. The Administrator acknowledged the lapse, attributing it to a staff member's health condition.
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital for five sampled residents. Staff typically contacted families by phone but did not follow up with written notifications, and the Administrator acknowledged the deficiency.
The facility failed to review and ensure the accuracy of a PASARR for a resident with Bipolar Disorder. The PAS, completed by hospital staff, incorrectly indicated no major mental illness, and the BOM did not review it for accuracy upon admission.
A resident with Neuromuscular Dysfunction of Bladder and moderately impaired cognition was found without a leg strap to secure his indwelling catheter tubing, despite facility policy and care plan requirements. Multiple staff confirmed the absence of the device, highlighting a failure to follow the care plan and physician's orders.
The facility failed to provide adequate ADL care, specifically showers and baths, for two residents who required assistance. One resident was found with dried feces and a strong odor, while another had a strong urine odor and grime on his body. Staff did not follow up to ensure proper bathing, and there was a lack of documentation and notification of refusals.
A facility failed to secure the indwelling catheter tubing for a resident with a leg strap, as required by policy and physician's order. The resident, with a diagnosis of Neuromuscular Dysfunction of the Bladder and moderately impaired cognition, was observed without the necessary leg strap, confirmed by both a CNA and an RN.
A resident on contact isolation received meals with washable dinnerware instead of disposable items, contrary to facility policy. Staff failed to follow isolation protocols, leading to potential cross-contamination.
The facility failed to provide influenza and pneumococcal vaccines to four residents who had requested them. Despite having signed consents, the vaccines were not administered, and the issue was only discovered during a survey. The ADON/IP nurse and DON were unaware of the lapse until it was pointed out by the survey team.
The facility failed to provide effective pest control related to roaches over a four-day survey period. Observations included a large roach moving from the kitchenette to the dayroom where residents were eating lunch, and then into a resident's room. Staff and residents confirmed the presence of roaches, despite pest control efforts. The pest control technician suggested that the roaches might be coming from outside and recommended additional measures, but the facility had not reported the issue to the pest control service.
The facility failed to post the Daily Nurse Staffing information for three out of four days during the survey. The facility's policy mandates that sufficient numbers of staff be provided in accordance with residents' care plans and the facility assessment. The Director of Nursing (DON) confirmed that the posted staffing information was outdated and should be updated at the end of every shift to reflect the actual staffing numbers.
Failure to Follow Physician Orders for Narcotic Discontinuation and Timely Antibiotic Initiation
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with physician orders and professional nursing standards for two residents. For Resident #2, physician orders dated 12/17/25 directed initiation of Oxycodone-Acetaminophen 5-325 mg every six hours and discontinuation of Hydrocodone-Acetaminophen 10/325 mg once the new medication became available. Pharmacy records showed the Oxycodone-Acetaminophen was delivered on 12/26/25 at 8:00 AM. However, the Order Summary Report still listed both narcotic medications as active, and the December 2025 MAR documented administration of both Oxycodone-Acetaminophen 5-325 mg and Hydrocodone-Acetaminophen 10-325 mg from 12/26/25 through 12/29/25. The Controlled Drug Receipt/Record/Disposition Form further confirmed that Hydrocodone/APAP 10/325 mg continued to be signed out and administered four times daily during this period, despite the discontinuation order. Resident #2 had been admitted on 6/4/25 with diagnoses including intervertebral disc degeneration of the lumbar region and had a BIMS score of 12 on the 2/5/26 MDS, indicating moderately impaired cognition. During interview, the DON confirmed that the Hydrocodone-Acetaminophen should have been discontinued when the Oxycodone-Acetaminophen became available on 12/26/25 and that nursing staff did not discontinue the medication as directed. RN #2 stated she administered both narcotic medications because both appeared as active on the MAR, did not question the duplicate opioid orders, did not verify whether Hydrocodone-Acetaminophen had been discontinued, and did not notify supervisory staff or pharmacy about the duplicate narcotic therapy. For Resident #1, the deficiency centers on a delay in implementing a newly ordered antibiotic following return from the hospital. Progress notes showed the resident was transferred to a local hospital on 12/24/25 for non-reactive pupils, unequal pupil size, and feeling hot to the touch, and returned later that day on medication for a UTI. The hospital After Visit Summary dated 12/24/25 indicated a diagnosis of UTI and a new order to start nitrofurantoin (Macrobid). The facility’s Order Summary Report reflected a physician order for Macrobid 100 mg via PEG tube twice daily for UTI, but with an initial start date entered as 12/30/29 and later clarified to a 10-day course starting 12/30/25. The MAR showed that Macrobid was not administered until 12/29/25, resulting in a five-day delay from the time the order was received on 12/24/25. Resident #1 had been admitted on 10/22/24 with diagnoses including anoxic brain damage, and the 1/22/26 MDS documented the resident as comatose and in a persistent vegetative state with no discernible consciousness.
Unlicensed GPN Functioned as LPN After Failing NCLEX
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services were provided by qualified and appropriately licensed personnel, as required by facility policy and state regulations. The facility’s policy on Compliance and Ethics – Risk Areas for Fraud and Abuse states that sufficient staffing must include staff with appropriate clinical training, licensure, and/or expertise to meet residents’ needs. A graduate practical nurse (GPN) was issued a temporary LPN permit with a defined expiration date and later took the NCLEX-PN exam. The NCLEX candidate report showed that the GPN did not pass the exam, and the state Board of Nursing’s published guidance states that if a new graduate fails the NCLEX, the temporary permit becomes invalid and the individual may no longer work under that permit. Despite receiving notification of failing the NCLEX, the GPN continued to work in the capacity of a licensed nurse for approximately five and one-half days, as confirmed by time cards, staffing schedules, and assignment sheets. During this period, she was assigned a full resident assignment and continued to administer medications, perform treatments, and document in residents’ medical records. The GPN acknowledged she did not verify the status of her permit with the Board of Nursing and did not inform facility administration of her failed exam. The DON confirmed she was unaware of the failed exam, believed the temporary permit remained valid until its printed expiration date, and that the facility had no system to verify exam results with the Board of Nursing, instead relying on self-reporting by the nurse. As a result, nursing care was provided by an individual who did not hold a valid license or permit during the identified timeframe.
Antipsychotic Medications Prescribed Without Appropriate Clinical Diagnosis
Penalty
Summary
The facility failed to ensure that antipsychotic medications were prescribed with appropriate, clinically documented diagnoses for one of six residents reviewed. A resident was admitted with diagnoses including Major Depressive Disorder, Single Episode, Unspecified, but the medical record did not indicate any other psychiatric or mood disorders. Despite this, the resident received multiple orders for antipsychotic medications, including Olanzapine and Haloperidol, for various indications such as mood, psychosis, and major depressive disorder. The Minimum Data Set (MDS) assessments consistently listed only depression as a psychiatric diagnosis, with no documentation of psychosis or other psychiatric conditions that would warrant the use of antipsychotic medications. Interviews with facility staff revealed that the pharmacist did not consistently verify that a specific supporting diagnosis was present for each medication, relying instead on the fact that medications can be used for multiple conditions. The DON described a process where the physician provides a diagnosis with each new medication order, and nurses enter this information into the electronic health record, which prompts for an associated diagnosis. Orders are reviewed daily, and the MDS nurse and consultant pharmacist are responsible for verifying the accuracy of diagnoses, particularly for psychotropic medications. However, the documentation reviewed did not support the use of antipsychotic medications for the resident in question.
Failure to Prevent Resident Elopement Through Unsecured Window
Penalty
Summary
The facility failed to provide adequate supervision and ensure environmental safety, resulting in a resident with moderate cognitive impairment exiting the building unnoticed and unsupervised. The resident, who had a Brief Interview for Mental Status (BIMS) score of 8 and was not previously identified as an elopement risk, was last seen inside the facility by a CNA at 6:00 AM and was found outside by a staff member at 6:30 AM. The resident had physically pushed out and removed the window screen in his room, exited through the window, and was found approximately 130 feet from the building, wearing only shorts and no shoes. Staff interviews and record reviews confirmed that the resident had not exhibited wandering or exit-seeking behaviors prior to the incident. The nurse on duty had last seen the resident at 4:30 AM during medication administration and wound care, and a CNA redirected the resident at 6:00 AM when he was found attempting to enter another resident's room. At some point after this, the resident managed to open his window, remove the screen, and leave the facility without being detected by staff. The facility's policies required the environment to remain as free of accidents and hazards as possible and for residents to receive supervision and assistance devices to prevent accidents. However, the failure to identify the resident as an elopement risk and the lack of effective environmental safeguards on the windows allowed the resident to exit the facility unnoticed. This incident placed the resident and other vulnerable individuals at risk for serious injury, harm, impairment, or death, and was determined to be Immediate Jeopardy and Substandard Quality of Care.
Removal Plan
- The Registered Nurse escorted the resident into the facility and assessed him with no signs or symptoms of injuries with vitals within normal limits.
- The Director of Nursing was notified by the nurse supervisor that the resident was outside on the curb and escorted back into the building. DON instructed the nurse supervisor to transfer Resident #1 to the secured unit for increased observation; as well as using a current daily census to perform a head count on all residents, and all residents were accounted for.
- The Administrator was notified of the incident.
- The Administrator contacted the Maintenance Supervisor to inspect all windows.
- The Maintenance Director reported to the facility to inspect the windows, all doors, windows, and keypads were working properly.
- The Administrator notified the State Agency.
- Licensed Social Worker interviewed Resident #1; he stated he just wanted to get air, and the Licensed Social Worker found no psychosocial harm.
- The Maintenance Director placed L brackets on all resident windows, which are metal shaped so that the windows are unable to open greater than six inches.
- An Emergency Quality Assurance Performance Improvement (QAPI) meeting was held that included the Administrator, Medical Director, DON, Regional Director of Operations, Regional Nurse Consultant, Unit Manager, Infection Preventionist, and Staff Development. The QAPI team discussed the adverse event, reviewed the immediate actions taken, reviewed policy and procedures. No changes were made to the policies and procedures. It was determined through staff and resident interview Resident #1 exited the facility by opening the window and removing the screen and going out for air. It was determined the Maintenance Director placed L brackets on all resident windows, which are metal shaped so that the windows are unable to open greater than six inches.
- An in-service was conducted by the Administrator for all staff prior to their oncoming shift and via telephone on missing residents, elopement risk policies, whom and when to notify if there is a missing resident, elopement books and arm band placement on each resident.
- All windows were verified to be in proper working order by the maintenance supervisor. All windows were secured with L shape brackets to prevent residents from exiting the facility. Maintenance will perform weekly visual inspections for four weeks and monthly thereafter to ensure that all windows and screens are in proper working order.
- Elopement drills were completed on all shifts by the maintenance supervisor and Assistant Administrator. Drills will be continued weekly for four weeks and monthly thereafter and will be brought in for review and recommendations during monthly QAPI. Any findings will be addressed immediately by the Administrator and/or Director of Nursing.
- All staff will be in-serviced for elopement/wandering. No staff will be allowed to work until they have received the in-service.
- The Nurse on duty moved Resident #1 to the secure unit, every one hour checks were put into place and fresh air walks were initiated.
- 100% of all residents were assessed by the Licensed Practical Nurse to verify that anyone deemed at risk for wandering or elopement proper interventions were in place. In-house census of 146 residents reviewed at this time and there was a total of 58 residents deemed at risk.
- 100% audit completed for all care plans to verify that any resident deemed a wandering or elopement risk were identified and updated.
- The Licensed Social Worker assessed Resident #1 to determine that there were no findings of psychosocial harm.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for a resident identified as a fall risk, resulting in a fall that caused the resident to sustain a mildly displaced fracture of the proximal right humerus. The care plan for the resident, who had a self-care deficit and was diagnosed with hemiplegia and hemiparesis following a cerebral infarction, required the use of a sit-to-stand lift for transfers. However, during a transfer from bed to wheelchair, the Certified Nurse Assistant (CNA) did not use the lift because its battery was not charged and attempted to transfer the resident manually, leading to the resident slipping and falling. The incident occurred when the resident requested to get up to smoke, and the CNA, believing she could manage the transfer without the lift, proceeded without it. This decision was contrary to the care plan's specified intervention, which was designed to ensure the resident's safety during transfers. The fall resulted in the resident being sent to the hospital for evaluation and treatment, where a fracture was confirmed. The CNA acknowledged not following the care plan, which contributed to the resident's injury.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident identified as a fall risk, resulting in a mildly displaced fracture of the proximal right humerus. The incident occurred when a Certified Nurse Assistant (CNA) attempted to transfer the resident from her bed to a wheelchair without using the sit-to-stand lift as outlined in the resident's care plan. The CNA reported that the resident's foot slipped during the transfer, causing the resident to fall onto the CNA, who attempted to break the fall. The resident was subsequently sent to the hospital for evaluation and treatment due to bruising and swelling in her right hand, where x-rays confirmed the fracture. The resident involved had a medical history of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, which contributed to her being a fall risk. The CNA admitted to not using the sit-to-stand lift because the battery was not charged, which was a deviation from the prescribed care plan. This failure to follow the care plan directly led to the resident's fall and subsequent injury. The incident was witnessed by another staff member, and the resident was assessed and treated for her injuries following the fall.
Failure to Implement Elopement Risk Interventions
Penalty
Summary
The facility failed to implement care plan interventions related to wandering and elopement risk for a resident, which resulted in the resident exiting the facility unsupervised and unnoticed by staff. The resident, who had been identified as an elopement risk due to impaired safety awareness and wandering behavior, was escorted to the therapy gym but was later found missing. The resident was discovered approximately one mile from the facility, walking in a residential area. The resident had been admitted with a diagnosis of Altered Mental Status and was identified as a wanderer in the Minimum Data Set assessment. Despite this, the care plan interventions to distract and monitor the resident were not effectively implemented. The staff failed to follow the care plan, which included offering pleasant diversions to prevent wandering. Interviews with facility staff, including the LPN and DON, confirmed that the care plan was not followed as required. The LPN acknowledged that the resident was not initially identified as an elopement risk upon admission, but later evaluations indicated the risk. The DON emphasized the importance of individualized care plans and confirmed the failure to implement the necessary interventions to ensure the resident's safety.
Removal Plan
- Staff identified the resident was missing and initiated missing resident procedures.
- Code W (elopement) protocols were initiated to notify all staff to begin searching.
- Staff members were assigned by Administrator and DON to search inside and outside of the building.
- The resident was located approximately 1 mile from the facility and returned safely.
- A headcount was completed to account for all residents.
- The Nursing Home Administrator notified the state agency of the elopement.
- The resident was assessed by LPN #1 with no signs of injury.
- The resident was assessed by the LSW with no psychosocial harm found.
- The Administrator and DON checked all doors and keypads for proper functioning.
- The inside door code was changed for emergency exit only.
- Entrance and exit through the therapy door are now restricted to visitors and staff.
- The Administrator notified the Attorney General's office of the incident.
- A QAPI committee meeting was held to review the incident and actions taken.
- 100% facility staff in-service completed regarding elopement/missing resident policies.
- 100% of all residents assessed for elopement risk.
- Twenty-seven new residents were added to the elopement/wandering list.
- 100% audit performed of care plans for those identified for elopement risk.
- 100% audit of wandering residents book completed to ensure all pictures are current.
- Elopement drills were performed on all shifts.
- Outside keypad to therapy door disabled and removed.
- Entrance and exit through therapy door is restricted to visitors and staff.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised. The resident was brought to the therapy gym and left unattended, leading to her being determined missing shortly after. She was found approximately one mile from the facility, having exited through the rehabilitation door, which was frequently used by visitors and staff. The resident had been admitted to the facility with a diagnosis of Altered Mental Status and was initially not identified as an elopement risk. However, during her stay, she showed signs of improvement and began exhibiting wandering and exit-seeking behavior. A second wandering evaluation confirmed her as a wandering risk, but despite this, she managed to leave the facility unsupervised. Interviews and record reviews revealed that the resident exited by following another person out the door before it closed completely. The facility's policies on accidents and incidents, as well as emergency procedures for missing residents, were not effectively implemented, leading to the resident's unsupervised exit. The incident highlighted a lapse in supervision and monitoring of residents at risk for wandering and elopement.
Removal Plan
- Staff completed a headcount compared to the daily census and all residents were accounted for.
- The Nursing Home Administrator notified state agency of the elopement.
- The resident was returned to her unit, assessed by LPN #1 and full body audit was completed. No signs or symptoms of injury, face was noted to be flushed, and resident took fluids cooperatively. NP assessed resident on unit, ordered labs, and UA (resulted negative). NP contacted the psychological NP for medication after ruling out acute episode.
- The resident was assessed by the LSW (Licensed Social Worker) with no psychosocial harm found.
- The Administrator and DON checked all doors and keypads for proper functioning, all were secure with no issues found.
- Inside door code changed and will be used for emergency exit only. Entrance and exit through therapy door are now restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility.
- The Administrator notified the Attorney General's office of the incident.
- Quality Assessment and Performance Improvement (QAPI) committee meeting was held involving missing resident.
- 100% facility staff in-service completed by Staff Development Coordinator, ADON, and Housekeeping Supervisor began regarding elopement/missing resident policies prior to returning to work.
- 100% of all residents assessed for elopement risk by ADON and Staff Development.
- Twenty-seven new residents added to elopement/wandering list.
- 100% audit performed of care plans for those identified for elopement risk to include visual monitoring and arm bands conducted by Regional Nurse Consultant.
- 100% audit of wandering residents book completed by Social Services to ensure all pictures are current.
- Elopement drills were performed on all shifts (7A-3P, 3P-11P, 11P-7A) by the Director of Nursing and the Staff Development Coordinator and will continue for 4 weeks then monthly for QAPI review and recommendations.
- Outside keypad to therapy door disabled and removed. Inside door code changed and will be used for emergency exit only.
- Entrance and exit through therapy door is restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility.
Failure to Store Food According to Professional Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an observation of the kitchen, it was found that Refrigerator #2 contained undated portioned glasses of orange juice and apple juice, as well as trays of sweet tea without labels or dates. Additionally, there were opened cartons of thickened lemon-flavored water with no opened dates and one with an expired manufacturer's use-by date. The freezer contained three frozen pie crusts without use-by dates or manufacturer's dates. The pantry had five overly ripe bananas with discolored black peelings that were not intact, exposing the inside of the bananas. The Certified Dietary Manager (CDM) acknowledged these issues and stated that it was the responsibility of the person who opened the food items to label them with the date they were opened. The CDM also reported that she was responsible for inventorying foods for quality, which was typically done twice weekly when the food truck made deliveries to the facility. Monthly in-service training on food safety was also mentioned by the CDM. The Dietary Aide Supervisor (DAS) confirmed that it was the CDM's responsibility to inventory foods for expiration dates and that the person who opened a food item was responsible for putting an open date on that item. The DAS also confirmed that the kitchen dietary staff received monthly in-service training. The Administrator acknowledged a lapse in the protocol by the kitchen staff to monitor for unlabeled, undated, and expired food items and stated that she expected the staff to make a daily inventory of the kitchen foods to ensure food quality standards were safe for the residents.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure resident council concerns were resolved in a timely manner for six months. The facility's policy required grievances to be reviewed within 24 hours and a written decision provided within 10 working days. However, multiple resident council concerns related to housekeeping, laundry, and dietary issues were not addressed or resolved, as evidenced by the lack of dates, signatures, and resolutions on the response forms. Specific concerns included issues with toilet paper, trash removal, cleaning, laundry mix-ups, and food quality and flavor. During interviews, residents expressed frustration over the lack of follow-up on their complaints, particularly regarding the poor flavor of the food. The Activities Director admitted to not recording food complaints every month, believing the food quality had improved based on her own experience. She also failed to complete the Old Business section of the meeting minutes, which would have informed residents of the facility's efforts to resolve their concerns. The Dietary Manager confirmed receiving and discussing food-related complaints but did not provide resolutions. The Administrator and Director of Nursing acknowledged the residents' complaints about the food but were unaware of the ongoing issues, believing they had been resolved. The Administrator had not attended resident council meetings in several months and was unaware of the residents' dissatisfaction with the food. This lack of communication and follow-up resulted in unresolved grievances and dissatisfaction among the residents.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to ensure a clean and comfortable environment for its residents, as evidenced by soiled privacy curtains in the rooms of two residents. During an observation and interview, Resident #6's privacy curtain was found to have long, brown streaks, and Resident #6, who has moderately impaired cognition, was unable to determine how long the curtains had been soiled. Similarly, Resident #27's privacy curtain had several circular brown spots, and although Resident #27, who is cognitively intact, confirmed the curtain was soiled, he was unsure of the duration. Housekeeper #2 confirmed the soiled conditions of the privacy curtains for both residents and stated that housekeeping staff are expected to check all curtains daily and notify the floor technician when curtains need to be changed. The Administrator was unaware of the soiled curtains and stated that she expected the staff to maintain a clean and home-like environment for the residents. The facility's policy on Resident Rights emphasizes the importance of providing a homelike environment, which was not upheld in this instance.
Improper Storage and Labeling of Medications and Biohazard Substances
Penalty
Summary
The facility failed to provide an opened date for a multi-use medication vial and did not ensure that medications, food, and biohazard substances were stored separately in two of the four medication rooms. During an interview, a registered nurse stated that nurses were responsible for dating multi-dose vials upon opening and for checking and discarding expired or undated medications every shift. However, an observation revealed a vial of Acetylcysteine 20% in the Rehab medication room that had been opened without a date or resident's name, which the Director of Nursing confirmed should have been labeled and subsequently disposed of. Additionally, an observation in the Central Unit medication room revealed a refrigerator marked as Biohazard containing food items, Med Pass, and grape juice. A registered nurse placed vials of blood inside the same refrigerator, which was confirmed to be an unsafe practice due to the risk of contamination. The Director of Nursing confirmed that food products should not be stored in a biohazard refrigerator, as it poses a contamination risk.
QAPI Committee Fails to Sustain Program During Leadership Transition
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain its program during transitions in leadership and did not maintain implemented procedures or monitor interventions put in place in March 2022. This failure was evident in two recited deficiencies related to residents' rights/environment and investigations. Specifically, the facility did not ensure a clean and comfortable environment for two residents, as evidenced by soiled privacy curtains. Additionally, the facility failed to complete a thorough investigation regarding an injury of unknown origin for one resident, despite previous citations for similar issues in March 2022. During an interview, the facility's Administrator, who was not employed at the time of the March 2022 survey, confirmed that the interdisciplinary team met monthly for QAPI meetings to discuss high-risk issues and provide interventions. However, the Administrator admitted that the QAPI committee had not discussed the soiled privacy curtains or the pelvic fracture investigation because she was unaware of the issues and believed the investigation was thorough. This indicates a lack of effective communication and monitoring within the QAPI committee, leading to repeated deficiencies.
Failure to Conduct Thorough Investigation of Injury
Penalty
Summary
The facility failed to complete a thorough investigation regarding an injury of unknown origin for a resident who was transferred to the hospital and diagnosed with bilateral pubic ramus fractures. The facility's investigation included interviews with the resident's medical providers, staff assigned to the resident prior to the hospital transfer, and the resident's roommate. However, the investigation did not include interviews with other residents who resided near or on the same hall as the injured resident to identify potential instances of abuse from staff, visitors, or other residents. The Administrator confirmed that the facility was aware of the fractures but was unable to determine how or when they occurred. The Administrator admitted that she did not contact the ambulance service or the hospital to investigate if an incident during transport or at the hospital could have caused the fractures. Additionally, the resident's cognitive skills were severely impaired, which required a staff interview for cognition. The facility's failure to conduct a comprehensive investigation, including interviews with other nearby residents and external parties involved in the resident's care, led to the deficiency.
Failure to Provide Written Notification of Transfers
Penalty
Summary
The facility failed to provide written notification of facility-initiated transfers to the residents or their Resident Representatives (RR) at the time of the transfer for five of 28 sampled residents. The facility's policy on emergency transfers or discharges requires notifying the representative or family member, but this was not followed. For instance, Resident #24, who was admitted with Chronic Obstructive Pulmonary Disease, was discharged to an acute hospital without written notification to the resident or RR. Similarly, Resident #75, admitted with Nontraumatic Acute Subdural Hemorrhage, was transferred to a local hospital without written notification to the resident or RR. Other residents, including Resident #76 with Cerebral Palsy, Resident #81 with Chronic Obstructive Pulmonary Disease, and Resident #126 following Joint Replacement Surgery, also experienced similar lapses in written notification during their transfers to acute hospitals. Interviews with staff revealed that while phone notifications were made to the RRs at the time of hospitalization, written notifications were not consistently provided. The Social Services Director confirmed that phone calls were made to the families, but no written notifications were sent. The Business Office Manager admitted to mailing notifications but did not keep copies due to a medical condition that limited her mobility. The Administrator acknowledged the failure to provide written notifications, attributing it to the Business Office Manager's health condition, and confirmed that it was the facility's expectation to notify residents or RRs in writing when a resident is transferred to the hospital.
Failure to Provide Written Notification of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital for five of the 28 sampled residents. Specifically, Residents #24, #75, #76, #81, and #126 were transferred to acute hospitals without their representatives receiving the required written notification. The facility's policy, dated 4/25/23, mandates that residents and/or their representatives be informed in writing of the bed hold policy, but this was not adhered to in these cases. The medical records for these residents did not contain copies of the written notifications, and interviews with the residents' representatives confirmed that they did not receive such notifications. Interviews with facility staff, including the Social Services Director, Business Office Manager, and Administrator, revealed that the failure to provide written notifications was due to a lapse in the process. The Social Services Director and Business Office Manager indicated that they typically contacted families by phone but did not follow up with written notifications. The Business Office Manager cited a personal health condition as a reason for not keeping copies of the letters. The Administrator acknowledged the deficiency and attributed it to the Business Office Manager's health issues, stating that it was the facility's expectation to inform families of the bed hold policy at the time of transfer.
Failure to Review and Ensure Accuracy of PASARR for Resident with Major Mental Illness
Penalty
Summary
The facility failed to ensure a Preadmission Screening (PAS) received from the hospital was reviewed and accurate, and a Preadmission Screening and Resident Review (PASARR) was initiated for a resident with a major mental illness. The PAS, completed by the acute care hospital staff prior to discharge, incorrectly indicated that the resident did not have a major mental illness. The resident was admitted to the facility with a diagnosis of Bipolar Disorder, which was not reflected in the PAS. The Business Office Manager (BOM) admitted to not reviewing the PAS for accuracy upon the resident's admission, leading to the oversight.
Failure to Implement Comprehensive Care Plan for Catheter Management
Penalty
Summary
The facility failed to implement a comprehensive care plan intervention related to a securing device for indwelling catheter tubing for one of the sampled residents. Resident #53, who has a diagnosis of Neuromuscular Dysfunction of Bladder and a moderately impaired cognitive status, was found without a leg strap to secure his indwelling catheter tubing. This was confirmed through multiple observations and interviews with the resident, a CNA, and an RN. The resident reported not having a leg strap, and both the CNA and RN confirmed the absence of the device during their respective observations. The facility's policy and the resident's care plan both indicated that the urinary catheter leg strap should be checked every shift and replaced as needed. Despite this, the resident did not have the required securing device in place. The Director of Nursing and the Care Plan Nurse both acknowledged that the care plan should be followed and that all residents with a catheter should have a leg strap in place. The deficiency was further supported by a physician's order dated 1/17/24, which also specified the need to check and replace the urinary catheter leg strap every shift.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care, specifically showers and baths, for two residents who required assistance. Resident #53 was observed with a strong odor of feces and dried feces on his body, indicating he had not received proper bathing. Despite the resident not refusing a shower, the CNA chose to give him a bed bath instead. The resident reported not receiving a shower for a long time, and records confirmed he had only received two showers in the past 30 days. The LPN admitted to not following up with CNAs to ensure residents received their baths or showers, and there was no notification of refusals documented for Resident #53. The resident had a moderately impaired cognitive status due to Alzheimer's Disease and required assistance with personal care. Resident #74 was also found in an unsanitary condition, with a strong urine odor in his room and grime on his body. The resident's family had complained about the lack of showers and the resident's dirty appearance. The CNA confirmed that the resident was dependent on staff for bathing and showers but often refused to go to the shower. Despite this, the resident only received five showers or baths in the past 30 days, with minimal documentation of bed baths. The DON and Administrator acknowledged the complaints but were unaware of the missed documentation and the lack of proper bathing. The resident had a severely impaired cognitive status due to Hemiplegia and Cerebral Infarction. Interviews with staff revealed a lack of follow-up and accountability in ensuring residents received their scheduled showers or baths. The DON and Administrator expected staff to provide ADL care and notify the Resident Representative (RR) of any refusals, but this was not consistently done. The facility's policy required daily baths per schedule and immediate notification of any refusals, which was not adhered to in these cases.
Failure to Secure Indwelling Catheter Tubing
Penalty
Summary
The facility failed to ensure that the indwelling catheter tubing for a resident was secured with a leg strap, as required by the facility's policy and the physician's order. The resident, who had a diagnosis of Neuromuscular Dysfunction of the Bladder and a moderately impaired cognitive status, was observed without a leg strap securing his suprapubic indwelling catheter. Both a CNA and an RN confirmed that the resident did not have a leg strap and had not been known to wear one. During interviews, the Director of Nursing and the Administrator acknowledged that all residents with an indwelling catheter should have a leg strap to secure the tubing. The failure to provide the leg strap was observed during multiple instances, indicating a lapse in adherence to the facility's policy and the physician's order, which aimed to prevent catheter-associated urinary tract infections and other complications.
Failure to Follow Contact Isolation Protocols
Penalty
Summary
The facility failed to handle dinnerware in a manner to prevent the possible spread of infection for a resident on contact isolation. Resident #8, who was admitted with diagnoses including Extended Spectrum Beta Lactamase (ESBL) Resistance and other infections, was observed receiving meals with washable dinnerware and silverware instead of disposable items. This was contrary to the facility's policy for contact precautions, which mandates the use of disposable dinnerware and utensils to prevent cross-contamination. The Licensed Practical Nurse (LPN) and Certified Nurse Aide (CNA) involved did not notice or follow the isolation protocol, leading to the meal tray being placed back with other residents' trays and returned to the kitchen without any distinction. The Dietary Manager and Infection Preventionist were unaware of the resident's isolation status, indicating a communication breakdown. The Admission Nurse could not recall if she had notified the dietary department about the contact isolation for Resident #8. The Director of Nursing (DON) confirmed that the procedures were not followed, as items taken into an isolation room should not be removed and mixed with other items. The Administrator also expected staff to adhere to the infection prevention policies, which were not followed in this instance, leading to a potential risk of infection spread.
Failure to Administer Requested Vaccines
Penalty
Summary
The facility failed to provide influenza and pneumococcal vaccines to four residents who had requested them. Resident #17, admitted with Bipolar Disorder, had a signed consent for the pneumococcal vaccine dated 12/28/23, but there was no documentation that the vaccine was administered. Similarly, Resident #31, admitted with Chronic Obstructive Pulmonary Disease (COPD), had a signed consent for the pneumococcal vaccine dated 12/1/23, but no documentation of administration was found. Resident #48, admitted with Hypertension, had a signed consent for the influenza vaccine, but there was no documentation that the vaccine was given. Resident #137, admitted with Osteomyelitis, had a signed consent for the pneumococcal vaccine dated 3/11/24, but again, no documentation of administration was found. During interviews, the Administrator explained that the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) was responsible for keeping up with the immunizations of the residents. The Director of Nursing (DON) and the ADON/IP nurse admitted they were unaware that the immunizations were not up to date until the survey team brought it to their attention. The IP nurse confirmed that the admission clerk was responsible for giving consents to the admission nurse to make management aware that vaccines had been requested. The DON confirmed that all four residents had signed consents for vaccines, but the vaccines were not administered. The facility's policy stated that influenza vaccines should be provided from October through March 31st and pneumococcal vaccines should be given in a timely manner, which was not adhered to in these cases.
Failure to Provide Effective Pest Control
Penalty
Summary
The facility failed to provide effective pest control related to roaches over a four-day survey period. Observations included a large roach moving from the kitchenette to the dayroom where residents were eating lunch, and then into a resident's room. Interviews with staff confirmed the presence of roaches, with one LPN noting that pest control services had been in the facility a couple of weeks ago. A CNA also confirmed seeing roaches several times, despite pest control efforts. During a resident council meeting, residents complained about large roaches in the building, expressing fear due to their size. Another observation noted a large roach moving across the dining room floor, with a resident confirming occasional sightings of roaches coming from outside the building. The facility's pest control vendor's technician confirmed seeing roaches in several residents' rooms during a visit on 3/21/24 and had switched to a stronger pesticide. The technician suggested that the roaches might be coming from outside and recommended a blow out outside the building to prevent them from entering. However, the facility had not reported the issue with roaches to the pest control service. The Administrator confirmed that pest control services sprayed the facility monthly but had not reported any issues with roaches to the pest control service.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the Daily Nurse Staffing information for three out of four days during the survey. The facility's policy, reviewed in October 2022, mandates that sufficient numbers of staff with the necessary skills and competency be provided in accordance with residents' care plans and the facility assessment. On April 1, 2024, at 10:05 AM, the posted staffing numbers were dated March 31, 2024, and did not reflect the current date. On April 2, 2024, at 8:30 AM, the posted staffing numbers were still dated March 31, 2024. On April 3, 2024, at 8:15 AM, the posted staffing numbers were dated April 2, 2024, and did not reflect the current date. During an interview on April 3, 2024, at 8:16 AM, the Director of Nursing (DON) confirmed that the posted staffing information was outdated and should be updated at the end of every shift to reflect the actual staffing numbers.
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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