Below 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 Tupelo Community Care Center during CMS and state inspections, most recent first.
A resident at high fall risk with impaired mobility and moderate cognitive impairment fell from bed, sustained skin tears and a right femur fracture, and staff confirmed the side rail was not raised despite the care plan requiring bilateral three-quarter length side rails. In a separate case, a cognitively intact resident with ESRD on dialysis had a 900 cc fluid restriction care plan, but staff did not track or document fluid intake on the MAR or flowsheet as ordered.
A resident with reduced mobility and moderate cognitive impairment was ordered three-quarter length side rails to assist with turning and repositioning in bed, but the rail was not maintained in the raised position. Staff found him on the floor after he rolled out of bed during sleep, with skin tears and right hip pain, and ED records showed a closed comminuted intertrochanteric fracture of the proximal right femur. The DON confirmed the rail was not raised at the time of the fall, and a CNA reported the left side rail was down when she responded.
An LPN administered medications via a resident’s G-tube while the room blind was half open, leaving the resident visible from outside the window and compromising bodily privacy. The facility policy required staff to protect resident privacy during care, and the DON confirmed this was a dignity concern. The resident had a G-tube, a history of cerebral infarction sequelae, and moderate cognitive impairment.
A resident's end-of-life wishes were not accurately documented when CPR/DNR consents signed by the resident's representative conflicted with physician and electronic orders listing the resident as full code. The DON and Administrator acknowledged the inconsistency, and the resident was cognitively intact with a BIMS of 15 and stated she wanted full code status.
Inaccurate MDS Weight Loss Coding: A resident with CHF had documented weight loss of 21 pounds, or 8.3%, in one month, but section K0300 of the MDS was coded as not showing a 5% or greater loss. The MDS nurse confirmed the error and stated the weight loss should have been coded. A BIMS was not completed because the resident was rarely/never understood.
A resident with ESRD on dialysis had a physician-ordered 900 cc daily fluid restriction, but the MAR and flowsheet did not document fluid intake amounts or shift totals. During observation, the resident received 360 mL of fluid at breakfast alone, excluding Nepro, and the DON and RD confirmed the restriction was not being tracked correctly and that Nepro had not been counted in the daily fluid allowance.
A resident with ESRD and dependence on renal dialysis did not receive an ordered Nepro supplement with breakfast even though the meal ticket directed that Nepro be added to all trays. An LPN confirmed the omission during observation, and the DM stated the dietary drink aide was responsible for reading the meal cards and providing the supplement.
Improper Glucometer Disinfection: An LPN cleaned a multi-use glucometer after a resident's blood glucose check by swiping the front and back three times with Sani-Cloth wipes for about 30 seconds, rather than keeping the meter wet for the required 2-minute contact time. The LPN said this was how she had been trained and the DON confirmed staff had recently been taught this method, even though the facility policy and manufacturer instructions required following the wipe's wet contact time. The resident involved had a history of cerebral infarction sequelae and gastrostomy care, with moderate cognitive impairment.
A resident in a rehabilitation unit was verbally abused by an LPN for reporting delayed pain medication administration. The resident, cognitively intact and admitted for a tibia fracture, was confronted harshly by the LPN, causing emotional distress. Witnesses, including therapy staff, confirmed the LPN's demeaning behavior, and trauma assessments documented the resident's emotional harm.
The facility failed to provide dementia care training to staff before they began caring for residents with dementia. Interviews revealed that CNAs had not received such training, and the Staff Development Nurse confirmed it was not part of the new hire orientation. The facility's records showed no policy or inclusion of dementia care in the New Hire Program, despite having residents diagnosed with Dementia and/or Alzheimer's Disease.
The facility did not ensure that handrails in resident hallways were securely affixed, affecting all four hallways. Observations showed multiple loose handrails, and the Administrator confirmed they had been loose for some time, acknowledging a potential safety issue. The handrails were made of PVC pipes, and while replacement was considered, floor replacement was prioritized. Communication about fixing the handrails was noted from May, but corporate approval was pending. The facility lacked a policy on repairs.
The facility failed to provide dementia care training to new hire staff before they began caring for residents with dementia. Interviews revealed that CNAs had been working for months without such training, and the Staff Development Nurse confirmed that dementia care was not part of the new hire orientation. The Administrator acknowledged the need for this training, given the number of residents with dementia in the facility.
The facility was found deficient in managing resources and providing adequate care. Issues included broken equipment, lack of dementia care training, and inadequate hygiene care for residents. Several residents did not receive proper baths, nail trimming, or shaving. Equipment maintenance was poor, with loose handrails and damaged wheelchairs posing safety risks. The administration failed to address these issues effectively, with inadequate communication and follow-up from staff.
The facility's QAPI/QAA committee failed to maintain and monitor interventions, resulting in repeated deficiencies in ADL care, psychotropic medication monitoring, and infection control. Despite efforts to implement a Performance Improvement Plan, issues persisted due to ineffective communication, lack of accountability, and oversight within the facility.
The facility failed to monitor side effects of psychotropic medications for three residents, despite policy requirements. Residents with major depressive disorder, generalized anxiety disorder, and dementia were prescribed multiple psychotropic drugs without documented side effect monitoring. Interviews with staff confirmed the absence of routine monitoring, highlighting a significant oversight in resident care.
A resident returned from the hospital with a C-Diff infection and was not placed on contact isolation precautions, despite having a physician's order for treatment. Observations showed no isolation measures in place, and interviews with staff confirmed the oversight. The DON and Infection Control nurse acknowledged the resident should have been isolated to prevent infection spread.
The facility failed to implement care plans for personal hygiene and incontinence care for several residents, leading to unmet needs. A resident with mild cognitive impairment did not receive shaving assistance, while another with moderate impairment had untrimmed, dirty nails. Cognitively intact residents reported not receiving regular baths or timely incontinence care, with observations confirming these deficiencies. Staff acknowledged the care plans were not followed.
The facility failed to provide adequate ADL assistance and incontinent care for several residents. A resident with mild cognitive impairment did not receive requested facial hair removal, while another with moderate impairment had untrimmed, dirty nails. A double amputee resident reported irregular bathing, confirmed by staff and documentation. Incontinent care was insufficient for three residents, with reports of being left in soiled conditions and delays in care. The DON acknowledged these failures, highlighting a lack of consistent care and communication within the facility.
The facility failed to provide adequate care for several residents, resulting in unmet personal hygiene needs and neglect. A resident's request for facial hair removal was ignored, while another did not receive a bath for several days. A resident was left in soiled conditions due to ignored call lights, and another had long, dirty fingernails. Staff interviews revealed chronic understaffing, with aides overwhelmed by numerous responsibilities, leading to inadequate care.
A resident in a LTC facility was unable to receive coffee for a month due to a broken coffee machine, impacting her right to self-determination and choice. The issue was raised in a Resident Council meeting, and staff interviews revealed that a temporary method of making coffee caused delays. The resident, who was cognitively intact, expressed that coffee was a significant social activity, and the lack of it affected her and other residents.
A facility failed to provide timely written notification of a hospital transfer for a resident, as required by their policy. The resident, who was cognitively intact, was transferred due to chest pains, but the Discharge/Transfer notice lacked a signature and proof of mailing to the resident's representative. The representative confirmed not receiving any notification.
A facility failed to provide a resident and their representative with written notice of the bed-hold policy during a hospital transfer. The resident, who was cognitively intact, was unaware of the policy, and the representative confirmed not receiving any notice. The Business Office Manager could not prove that the notice was mailed, despite the facility's policy requiring such notification.
A resident was inaccurately coded in the MDS as receiving insulin injections, despite not being diabetic and having no record of insulin administration. The MDS Nurse confirmed the error, and the facility's policy requires accurate assessments to reflect residents' conditions.
A resident's wheelchair was found to have exposed foam on both armrests due to cracked protective covering, which had been in this condition for some time. The resident, who was cognitively intact, reported the roughness of the exposed areas. The DON confirmed the need for replacement to prevent skin injury and acknowledged the oversight in the repair system. The resident had diagnoses of muscle wasting, atrophy, muscle weakness, and cerebral infarction.
A facility failed to maintain a clean environment in a resident's room, where a fall protection floor mat was found covered in stains. Despite daily cleaning protocols, the mat remained unclean, and the facility lacked a specific policy for cleaning such mats. Staff interviews confirmed the necessity of daily cleaning to prevent infection spread.
Failure to Implement Fall and Fluid Restriction Care Plans
Penalty
Summary
The facility failed to implement the fall care plan for Resident #3. The resident was admitted with diagnoses including acquired absence of the left leg above the knee and other reduced mobility, and had a BIMS score of 9, indicating moderate cognitive impairment. The care plan, initiated for high fall risk related to impaired mobility and unawareness of safety precautions, directed use of three-quarter length side rails on both sides of the bed as enablers to assist with turning and repositioning, with instructions to release and reposition every two hours and as needed. During an observation, Resident #3 was found in bed with three-quarter length side rails raised on both sides, but the accident report documented that staff heard yelling and found the resident lying under the bedside table beside the bed with skin tears to both elbows and right hip pain. The resident stated he rolled out of bed during sleep and believed his hip was broken, and emergency department records confirmed a closed comminuted intertrochanteric fracture of the proximal end of the right femur. Interviews with the resident, a CNA, the DON, and the MDS nurse confirmed the side rail was not raised at the time of the fall and that the fall care plan was not implemented. The facility also failed to implement the fluid restriction care plan for Resident #87. The resident was admitted with diagnoses including end stage renal disease and dependence on renal dialysis, and had a BIMS score of 15, indicating cognitive intactness. The care plan identified a 900 cc fluid restriction with amounts assigned for breakfast, lunch, dinner, medications, and snacks, and the MAR included an order to record fluid intake in 24 hours. Review of the December 2025 MAR showed the order was only initialed by the nurse, with no documentation of fluid intake amounts recorded, and the December 2025 flowsheet showed no evidence that fluid intake was monitored or documented. The DON stated fluid restrictions were to be tracked on the MAR and totaled at the end of each shift, and the MDS nurse confirmed the care plan was not followed because staff were not tracking and documenting fluid intake.
Side Rail Not Raised, Resident Fell From Bed and Fractured Hip
Penalty
Summary
The facility failed to ensure adequate accident prevention for one resident reviewed for accident hazards when the resident's ordered three-quarter length side rail was not maintained in the raised position while he was in bed. The resident had diagnoses including acquired absence of the left leg above the knee and other reduced mobility, and a BIMS score of 9 indicating moderate cognitive impairment. The Medication Review Report showed an order for three-quarter length side rails to be used as enablers to assist with turning and repositioning while in bed, with instructions to release and reposition every two hours and as needed. A facility statement also indicated there was no specific policy pertaining to accident prevention. An accident report documented that staff heard yelling and found the resident lying under the bedside table beside the bed, with skin tears to both elbows and complaints of right hip pain; the resident stated he had rolled out of bed during sleep. Emergency Department records showed he was diagnosed with a closed comminuted intertrochanteric fracture of the proximal end of the right femur. During interviews, the resident stated he rolled out of bed because the side rail was not raised, and the DON confirmed the side rail was not in the raised position at the time of the fall and that it should have been raised to prevent him from rolling out of bed. CNA #1 reported the left side rail was not raised when she responded, and CNA #2 stated the resident would not have been physically able to reach the lever used to lower the side rail.
Failure to Maintain Privacy During G-Tube Medication Administration
Penalty
Summary
The facility failed to maintain resident privacy during medication administration for a resident with a gastrostomy tube. During an observed medication pass, an LPN administered medications via the resident’s gastrostomy tube while the room blind was half open, allowing the resident to be visible from the back parking lot and compromising bodily privacy. The facility policy on dignity states that staff are to promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures. The LPN confirmed the blind was left open during the medication administration and stated this was a privacy concern because the resident’s stomach and tube were visible to people outside the window. The DON also confirmed that residents were expected to be provided privacy during care and that this was a dignity concern. The resident had diagnoses including unspecified sequelae of cerebral infarction and encounter for attention to gastrostomy, and the MDS showed a BIMS score of 12, indicating moderate cognitive impairment.
Inaccurate Code Status Documentation
Penalty
Summary
The facility failed to ensure the desired code status of one resident was accurately documented. Resident #10 had a Consent for Cardiopulmonary Resuscitation signed by the resident's representative stating that CPR should not be done, and a Do Not Resuscitate consent signed by the resident's representative and the physician indicating resuscitation would be medically futile. However, the resident's electronic order listing and a physician telephone order both documented the resident as full code. During interviews, the DON and Administrator acknowledged that the resident had the right to choose end-of-life care and that the documentation should reflect the resident's wishes. They also acknowledged the conflicting records, including the full code orders and the DNR-related consents. Resident #10 was cognitively intact with a BIMS score of 15, had Type 1 Diabetes Mellitus, and stated she desired full code status and was capable of signing her own documents.
Inaccurate MDS Weight Loss Coding
Penalty
Summary
Ensure each resident receives an accurate assessment. Based on record review, staff interview, and facility policy review, the facility failed to accurately complete section K of the Minimum Data Set (MDS) for one resident. Resident #100’s weight records showed 252 pounds on 10/08/25 and 10/28/25, 249.6 pounds on 11/03/25, and then 230.8 pounds on 11/13/25 and 230.7 pounds on 11/18/25, reflecting a significant weight loss of 21 pounds and 8.3% in one month. However, the MDS with an ARD of 11/20/25 coded section K0300 as not having a weight loss of 5% or more in the last month, which was inaccurate. The MDS Nurse stated she was responsible for section K and confirmed she made an error and that weight loss should have been coded. The resident was admitted with chronic combined systolic and diastolic congestive heart failure, and a BIMS was not conducted because the resident was rarely/never understood.
Failure to Track and Document Fluid Restriction Intake
Penalty
Summary
The facility failed to ensure fluid intake was managed, tracked, and documented in accordance with a physician-ordered fluid restriction for Resident #87, who had End Stage Renal Disease and was dependent on renal dialysis. The resident had an order dated 7/16/25 for a 900 cc fluid restriction in 24 hours, broken down by meals, medications, and snacks, but the December 2025 MAR contained no documented fluid intake amounts and was only initialed by the nurse. The December 2025 flowsheet also showed no evidence that fluid intake was monitored or documented. Resident #87 also had an order for Nepro/Carb Steady oral liquid twice daily, and the breakfast tray ticket instructed that Nepro be added to all trays. On observation, the resident received breakfast with 240 mL of water and 120 mL of apple juice, totaling 360 mL of fluid at one meal, excluding the Nepro supplement. The DON stated fluid restrictions were to be tracked on the MAR and totaled at the end of each shift, confirmed this had not been done for the resident, and stated the resident could be receiving too much fluid, which could contribute to fluid volume overload. The RD stated she had not calculated the Nepro into the resident's daily fluid allowance and acknowledged the resident's fluid intake was not being documented or totaled at the end of the shift.
Ordered Nutritional Supplement Omitted From Breakfast Tray
Penalty
Summary
The facility failed to ensure meals were served in accordance with a resident’s physician-ordered nutritional requirements for 1 of 4 residents reviewed for dining. Resident #87 had an order on the meal ticket dated 12/09/25 for Nepro, 1 carton, with notes to add Nepro to all trays, but during an observation at 8:06 AM the resident’s breakfast tray did not include the Nepro supplement. The resident was observed sitting up in a wheelchair in her room with an untouched tray that contained bacon, scrambled eggs, toast, water, and apple juice, and she stated she only received the supplement sometimes. An LPN observed and confirmed at 8:12 AM that Resident #87 did not receive the ordered Nepro supplement with breakfast and stated the meal provided should match the meal ticket. The Dietary Manager later stated she was aware the resident did not receive Nepro, explained that it was the dietary drink aide’s responsibility to read the meal cards and provide the supplements, and described the omission as a human mistake. Resident #87’s record showed diagnoses including End Stage Renal Disease and dependence on renal dialysis, and the MDS dated 11/02/25 showed a BIMS score of 15, indicating the resident was cognitively intact.
Improper Glucometer Disinfection
Penalty
Summary
The facility failed to clean and disinfect a multi-use glucometer according to the manufacturer's instructions and the required wet contact time for one of two glucometers observed during a blood glucose check for Resident #16. During the observation, an LPN completed the blood glucose check and then cleaned the glucometer by swiping the front and back of the machine three times for a total of 30 seconds using Sani-cloth germicidal wipes. The LPN stated this was how she had been trained and that it was the method the facility policy instructed staff to use, but she was not aware of the wet contact time required on the back of the Sani-cloth container. She acknowledged that improper cleaning could spread germs to other residents because the glucometer was used on multiple residents. Facility policy for the Assure Prism Multi Blood Glucose Monitor System stated staff should follow the manufacturer's disinfection procedures. The manufacturer's instructions identified Super Sani-Cloth Germicidal Disposable Wipes for cleaning and disinfecting the meter and required meter surfaces to remain wet according to the wipe manufacturer's contact times. The wipe instructions reviewed by surveyors stated to allow the surface to remain wet for two minutes. The DON stated staff had recently attended training and were taught to swipe over the glucometer three times on the front and back, and she confirmed she was aware of the required wet contact time. Resident #16 was admitted with diagnoses including unspecified sequelae of cerebral infarction and encounter for attention to gastrostomy, and the MDS showed a BIMS score of 12, indicating moderate cognitive impairment.
Resident Verbal Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically an LPN, who confronted the resident for reporting not receiving pain medications in a timely manner. The resident, who was cognitively intact with a BIMS score of 15, was admitted for short-term rehabilitation following a tibia fracture. The incident involved the LPN speaking harshly and in a demeaning tone to the resident, which was witnessed by other staff members, including a Speech Therapist and a Physical Therapy Assistant. These staff members provided written statements corroborating the resident's account of the LPN's confrontational behavior. The resident reported feeling emotionally unsafe and was visibly upset, crying after the encounter with the LPN. The resident had a history of requesting pain medications prior to therapy sessions, which were not administered in a timely manner, leading to the confrontation. The resident expressed that the LPN's behavior was the worst she had experienced, despite her background as a former City Police Officer. The resident's emotional distress was further documented in trauma assessments conducted by a Licensed Social Worker, which confirmed the resident's trauma following the incident. Interviews with other staff members, including CNAs and the Director of Rehabilitation, supported the resident's claims of the LPN's inappropriate conduct. The facility's investigation concluded that while abuse was not substantiated, the LPN exhibited poor customer service. However, the evidence from staff interviews and written statements indicated that the LPN's actions were perceived as abusive by the resident and other staff members, highlighting a failure to ensure the resident's right to be free from abuse.
Lack of Dementia Care Training for Staff
Penalty
Summary
The facility failed to ensure that staff were trained on dementia care before caring for residents with dementia. This deficiency was identified during a survey, where it was found that the facility did not have a policy on training staff or assessing their competency in dementia care. Interviews with Certified Nurse Assistants (CNAs) revealed that they had not received any training on dementia care, despite working at the facility for about four months. The Staff Development Nurse confirmed that dementia care training was not part of the new hire orientation, and the Administrator acknowledged that staff should receive such training due to the number of residents with dementia. The facility's records showed that the last dementia care in-services were conducted in August and October of the previous year, and the New Hire Program did not include dementia care training. The Facility Assessment Tool also did not list dementia care as a required topic for new hires. The Resident Matrix indicated that there were 16 residents with a diagnosis of Dementia and/or Alzheimer's Disease, with two residing on the B Hall. This lack of training and policy implementation led to a deficiency in the care provided to residents with dementia.
Loose Handrails in Resident Hallways
Penalty
Summary
The facility failed to ensure that handrails in the resident hallways were permanently affixed to the walls, affecting all four hallways. Observations on September 9, 2024, revealed multiple loose handrails with their ends not securely attached to the walls. During an interview, the Administrator confirmed that the handrails had been loose for some time and acknowledged that they could pose a safety issue for residents. The Administrator mentioned that the handrails were made of PVC pipes and that they had been considering replacing them, but prioritized floor replacement first. Communication from a company regarding options for fixing the handrails was noted from May 10, 2024, but approval from corporate had not yet been obtained. The facility also lacked a policy on facility repairs, as indicated by a statement from the Executive Director dated September 11, 2024.
Lack of Dementia Care Training for New Hires
Penalty
Summary
The facility failed to ensure that new hire staff were trained on dementia care before caring for residents with dementia. This deficiency was identified during a survey where it was found that the facility did not have a policy on training staff or assessing their competency in dementia care. Interviews with two Certified Nurse Assistants (CNAs) revealed that they had been working at the facility for about four months without receiving any training on dementia care. One CNA mentioned that she was unaware of any special considerations for dealing with residents with dementia, although she did not have any residents with such a diagnosis in her assigned area. Further interviews with the Staff Development Nurse and the Administrator confirmed that dementia care training was not part of the new hire orientation. The Staff Development Nurse, who had been in her role for about five years, acknowledged that dementia care training had never been included in the orientation process. The Administrator also confirmed that staff should receive dementia care training due to the significant number of residents with dementia in the facility. A review of the New Hire Program and the Facility Assessment Tool corroborated the absence of dementia care as a required training topic, despite the presence of 16 residents diagnosed with dementia or Alzheimer's Disease in the facility.
Deficiencies in Resident Care and Facility Management
Penalty
Summary
The facility was found to be deficient in several areas during a survey conducted over three days. The administration failed to manage resources effectively, as evidenced by the lack of a policy on administration or administrative staff, and the absence of dementia care training in new hire orientation. The facility's Executive Director and Director of Nursing (DON) were unaware of several ongoing issues, including broken equipment and inadequate care for residents, which were not addressed in a timely manner. For instance, the coffee maker used for residents had been broken for about two months, causing delays in service, and the facility's handrails had been loose for a while, posing a safety risk. The survey revealed multiple instances of inadequate care for residents. Several residents did not receive proper hygiene care, such as regular baths, nail trimming, and shaving, which are essential for their well-being. Resident #43 did not receive assistance with shaving, and Resident #59 complained about not having a bath since the previous Tuesday. Additionally, Resident #68 experienced delays in receiving incontinent care, and Resident #352 was often found soiled during therapy sessions, indicating a lack of timely care by the staff. The DON admitted that aides were expected to make rounds every two hours, but this was not consistently happening. The facility also failed to maintain equipment and the environment in a safe and sanitary condition. Resident #84's wheelchair arms needed replacement to prevent skin injury, and the facility's handrails were loose, which could lead to accidents. The DON and Administrator acknowledged these issues but had not implemented effective measures to address them. The lack of communication and follow-up was evident, as the DON relied on charge nurses and unit managers to ensure tasks were completed, but this oversight was insufficient. The facility's performance improvement plan did not address the root causes of these deficiencies, leading to ongoing issues with resident care and safety.
Repeated Deficiencies in ADL Care and Monitoring
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee failed to maintain and monitor the interventions they had implemented, leading to repeated deficiencies in several areas. These deficiencies were initially cited during a recertification survey on May 18, 2023, and were found again during a subsequent survey on September 9, 2024. The repeated deficiencies included failure to implement an Activities of Daily Living (ADL) care plan, assist residents with ADLs, monitor for side effects of psychotropic medications, and place an infectious resident in contact isolation. The facility's inability to sustain an effective Quality Assurance Program was evident as these issues persisted across multiple surveys. Interviews with the Director of Nurses (DON) and the Administrator revealed a lack of effective communication and follow-up within the facility. The DON admitted to relying on charge nurses and Unit Managers to ensure tasks were completed, but acknowledged that this did not always happen. The Administrator confirmed that staffing concerns, ADL care, or care plans were not addressed during QAPI/QAA meetings. Despite efforts to implement a Performance Improvement Plan (PIP) and assign administrative nurses and Unit Managers to monitor resident care, no significant issues were identified or addressed. Both the DON and Administrator recognized a lack of accountability and oversight, contributing to the ongoing deficiencies.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure residents were free from unnecessary drug use by not monitoring for side effects of psychotropic medications for three residents. The facility's policy required routine review and monitoring for side effects of these medications, but this was not adhered to. Resident #44, who was admitted with major depressive disorder and generalized anxiety disorder, was prescribed multiple psychotropic medications, including Duloxetine, Quetiapine Fumarate, Lorazepam, and Divalproex Sodium. Despite these prescriptions, there was no evidence of side effect monitoring. Similarly, Resident #54, with severe cognitive impairment and diagnoses including dementia with psychotic disturbance and major depressive disorder, was on a regimen of psychotropic medications such as Quetiapine Fumarate, Memantine, and others, yet lacked documented side effect monitoring. Resident #87, admitted with generalized anxiety disorder and major depressive disorder, was also prescribed several psychotropic medications, including Buspirone, Fluoxetine, and Trazodone, without any monitoring for side effects. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the absence of routine monitoring for side effects. The Pharmacy Consultant emphasized the importance of monitoring for adverse reactions, such as over-sedation, to determine if medication adjustments were necessary. This lack of monitoring represents a significant oversight in the care of residents receiving psychotropic medications.
Failure to Implement Contact Precautions for C-Diff Infection
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident who returned from the hospital with a Clostridium Difficile Colitis (C-Diff) infection. Despite having a physician's order for Fidaxomicin to treat C-Diff, the resident was not placed on contact isolation precautions upon their return. Observations revealed the absence of isolation barrels and signage indicating contact precautions in the resident's room. Interviews with the resident and staff confirmed the oversight, with the Licensed Practical Nurse (LPN) acknowledging that the resident was not on contact precautions and should have been. The Director of Nursing and the Assistant Director of Nursing/Infection Control nurse both confirmed that the resident should have been placed on contact isolation to prevent the spread of infection. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had been admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease and had a history of long-term antibiotic use. The failure to implement contact precautions was a clear deviation from the facility's policy and the Centers for Disease Control (CDC) guidelines for managing C-Diff infections.
Failure to Implement Care Plans for Personal Hygiene and Incontinence Care
Penalty
Summary
The facility failed to implement developed care plans for several residents, leading to unmet personal care needs. Resident #43, who has a mild cognitive impairment, expressed a preference for facial hair removal by shaving, which was not provided despite being part of her care plan. The Director of Nursing and the MDS Assistant confirmed that the care plan, which included shaving as part of the bathing routine, was not followed. Resident #151, with moderate cognitive impairment, had a care plan for nail care that was not implemented. The resident's fingernails were observed to be long and dirty, and she expressed a desire for them to be trimmed. The Director of Nursing confirmed the care plan for nail care was not followed, and the MDS Assistant acknowledged the failure to implement the care plan. Residents #59, #68, #351, and #352 experienced deficiencies in bathing and incontinent care. Resident #59, who is cognitively intact, reported not receiving regular baths as per his care plan. Resident #68, also cognitively intact, was left in wet clothing for an extended period, and Resident #351 was observed in urine-soaked clothing. Resident #352, who is cognitively intact, reported delays in receiving incontinence care, corroborated by a Physical Therapy Assistant who noted consistent issues with the resident being soiled during therapy sessions. The MDS Nurse confirmed that the care plans for these residents were not followed.
Deficiencies in ADL Assistance and Incontinent Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents who were dependent on staff. Resident #43, who had a mild cognitive impairment, expressed a preference for facial hair removal, which was not fulfilled by the staff despite her requests. Observations confirmed the presence of facial hair, and the Director of Nursing (DON) acknowledged the failure to provide the necessary grooming care. Similarly, Resident #151, with moderate cognitive impairment, had long, dirty fingernails, and despite expressing a desire for nail care, the facility did not address this need. Resident #59, a double above-knee amputee, reported not receiving regular baths, stating he had not been bathed since the previous Tuesday. The resident required assistance with bathing, and documentation confirmed missed bathing schedules. Staff interviews revealed that the resident only received baths when a specific CNA was on duty, and complaints made to an LPN were not escalated or addressed. This lack of consistent bathing care was acknowledged by the staff involved. Incontinent care was also inadequately provided for Residents #68, #351, and #352. Resident #68, who was cognitively intact, reported being left in soiled conditions over the weekend, with staff failing to return after turning off the call light. The DON confirmed the incidents and the failure to provide timely care. Resident #351 was observed in wet clothing, with family members reporting consistent issues with incontinence care. The DON was unaware of these concerns until recently. Resident #352 experienced delays in being changed, with therapy staff noting the issue during sessions. The DON was not informed of these delays, indicating a communication breakdown within the facility.
Inadequate Staffing Leads to Neglect in Resident Care
Penalty
Summary
The facility failed to provide adequate nursing care for six out of seven residents reviewed for Activities of Daily Living (ADL) during the survey. Resident #43 expressed a preference for facial hair removal, which was not attended to by the staff despite multiple requests. Similarly, Resident #59, a double above-knee amputee, reported not receiving a bath since the previous Tuesday, and this was confirmed by the Certified Nurse Assistant (CNA) assigned to him. The documentation corroborated that the resident did not receive a bath on the specified date, highlighting a lapse in personal hygiene care. Resident #68 experienced neglect over a weekend when her call light was ignored, leaving her in soiled conditions for an extended period. The Director of Nursing (DON) acknowledged awareness of the incidents and took disciplinary actions against the aides involved. However, the resident reported that the aides did not check on her every two hours as expected. Resident #151 also suffered from neglect, with long fingernails and a brown substance under them, which the DON confirmed should have been addressed to prevent infections. Additional issues were observed with Resident #351, who was found in a urine-soaked state after returning from therapy, and Resident #352, who experienced delays in being changed after meals, affecting his therapy sessions. Interviews with staff revealed chronic understaffing, with aides responsible for numerous tasks and residents, leading to inadequate care. The facility's staffing policy based on resident acuity was insufficient to meet the needs of the residents, as evidenced by the numerous complaints and observations of neglect.
Resident's Right to Coffee Denied Due to Broken Machine
Penalty
Summary
The facility failed to ensure a resident received coffee as desired, which is a violation of the resident's right to self-determination and choice. The deficiency was identified through observation, resident and staff interviews, and record reviews. A resident expressed that she had not received coffee for the past month due to a broken coffee machine in the kitchen. This issue was also raised during a Resident Council meeting, where residents were informed that the coffee machine was being repaired. The resident emphasized that coffee was a significant social activity for her and other residents, and the lack of it had negatively impacted their experience. Interviews with the Dietary Manager and the Administrator revealed that the coffee machine had been broken for about two months, and a temporary method of boiling water and using a filter was implemented, which caused delays in serving coffee to residents. The Dietary Manager acknowledged the residents' complaints and frustration, and the Administrator confirmed awareness of the issue but underestimated the duration of the problem. The Administrator also mentioned that a backup method was in place but was unaware of the delays it caused. The resident involved was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15.
Failure to Notify Resident and Representative of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification of a discharge/transfer to the hospital for Resident #45, as required by their policy. The policy, titled 'Emergency Transfers Procedures,' mandates that an Emergency Transfer notice, including the date, reason for transfer, location, and contact information for State Agencies to initiate the appeal process, should be provided to the resident or their representative as soon as practicable. However, during a review, it was found that the Discharge/Transfer notice for Resident #45 was dated a day after the transfer and lacked a signature from either the resident or their representative. Interviews and record reviews revealed that the Business Office Manager admitted to mailing the forms to the responsible party but had no proof of mailing. The resident's representative confirmed not receiving any notification regarding the discharge/transfer. Resident #45, who was cognitively intact with a BIMS score of 15, was transferred to the emergency department due to chest pains. The facility admitted Resident #45 in December 2022 with a diagnosis related to urinary tract care, and the failure to notify the resident or their representative in writing of the hospital transfer was identified as a deficiency.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident and their representative during a transfer to a hospital. This deficiency was identified for one of three residents reviewed for bed holds. The facility's policy, titled F-625 Notice of Bed-Hold Policy, requires that at the time of a resident's transfer for hospitalization, the nursing facility must provide written notice of the bed-hold policy to both the resident and their representative. However, in the case of Resident #45, this procedure was not followed. Resident #45, who was admitted to the facility with a diagnosis related to urinary tract care, was transferred to the hospital without receiving the required bed-hold notice. During an interview, the resident stated she was unaware of the bed-hold policy. A review of the Bed-Hold Notice form for this resident showed a date of notice but lacked a signature from either the resident or their representative. The Business Office Manager admitted that the notices are mailed out but could not provide proof that the notice was sent. The resident's representative confirmed that they had never received any bed-hold notice, despite the resident having been hospitalized multiple times.
Inaccurate MDS Coding for Insulin Administration
Penalty
Summary
The facility failed to accurately complete section N of the 5-day Minimum Data Set (MDS) for one of the sampled residents. Specifically, Resident #22 was incorrectly coded as having received insulin injections for seven days during the 7-day look-back period since admission. However, upon review of the Medication Administration Record (MAR) for August 2024, it was found that Resident #22 did not receive insulin or any injections during this period. An interview with the resident confirmed that he was not diabetic and had never taken insulin injections. The MDS Nurse acknowledged the coding error, confirming that Resident #22 did not have a physician order for insulin. The facility's policy on MDS Assessment, revised in June 2023, mandates that assessments be conducted accurately to reflect the resident's condition and facilitate the development of an individualized care plan. The Administrator expressed that her expectation was for MDS assessments to be completed accurately. Resident #22 was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease and had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment.
Wheelchair Maintenance Deficiency
Penalty
Summary
The facility failed to ensure a wheelchair was in good, safe condition for one of the sampled residents. During an observation, it was noted that the wheelchair of Resident #84 had both armrests with foam exposed due to cracked protective covering. The left armrest was entirely affected, and the right armrest had a damaged area approximately four inches by one inch. Resident #84, who was cognitively intact with a BIMS score of 15, reported that the wheelchair had been in this condition for a while and that the exposed areas were rough to touch. The Director of Nursing confirmed that the wheelchair arms needed replacement to prevent potential skin injury and acknowledged that the issue was overlooked and not entered into their repair system. The resident had been admitted with diagnoses including muscle wasting, atrophy, muscle weakness, and cerebral infarction.
Failure to Maintain Clean Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of the observed rooms, specifically room D5 B. During an observation, a fall protection floor mat was found to be covered in black and brown dried stains, and a clump of a brown leaf tobacco product was observed on the floor next to the mat. Although the tobacco product was cleaned up later, the floor mat remained stained. The facility lacked a policy on cleaning floor mats, as revealed by a document signed by the Executive Director. Interviews with staff, including a CNA, the DON, a housekeeper, and the Assistant Director of Nursing/Infection Control Nurse, confirmed that the floor mats should be cleaned daily to prevent infection spread. The CNA acknowledged the mat was filthy, and the DON emphasized the importance of daily cleaning. The housekeeper stated that resident rooms are cleaned daily, including mopping under mats and sanitizing the top of mats. The Assistant Director of Nursing/Infection Control Nurse reiterated the need for daily cleaning and sanitization of the mats to reduce infection risk.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tupelo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Tupelo | 0.5 mi | ★★★★★ | 11 | 0 |
| Cedars Health Center | 4.6 mi | ★★★★★ | 5 | 1 |
| Courtyards Comm Living Center | 15.8 mi | ★★★★★ | 0 | 0 |
| The Meadows | 15.8 mi | ★★★★★ | 8 | 0 |
| Shearer-richardson Memorial Nursing Home | 17.2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.