Citations in Mississippi
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Mississippi.
Statistics for Mississippi (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Mississippi
Surveyors identified multiple deficiencies in food storage and handling, including undated and unlabeled prepared foods, exposed and spoiled produce, and improper handling of ready-to-eat foods by staff using gloved hands. Dry goods were left uncovered, and items requiring refrigeration were improperly stored. Staff and administration acknowledged these lapses in food safety and sanitation protocols.
The facility did not promptly review or resolve repeated resident grievances about inadequate housekeeping, particularly on weekends when no dedicated staff were assigned. Multiple residents reported ongoing issues with unclean rooms and unemptied trash, and these concerns were documented over several months without effective response from management, despite their awareness of the problem.
Staff did not report allegations of verbal abuse by an LPN towards two residents, despite multiple accounts describing the nurse's behavior as loud and demeaning. Additionally, multiple reports of stolen resident funds were not reported to the State Agency, with the Administrator stating a lack of awareness of the reporting requirement. These actions were not in accordance with facility policy, which mandates immediate reporting of such incidents.
A wound care cart containing medications such as Nystatin, Santyl, and Dakin's solution was left unlocked and unattended for fifteen minutes, with wound cleanser unsecured on top. An RN later returned to secure the cart. Both the RN and DON confirmed that the cart should have been locked at all times when not in use, in accordance with facility policy.
Two cognitively intact residents reported that an LPN spoke to them in a loud, demeaning, and intimidating manner, with one resident feeling degraded and afraid after a medication-related interaction. Another resident described the LPN as using a rough tone and intimidating residents. Staff interviews confirmed the LPN's negative, vulgar, and insulting behavior towards both residents and staff, including the use of profane language. The facility's policy prohibits abuse, but these incidents demonstrate a failure to prevent verbal abuse.
Multiple residents reported theft of personal funds, with amounts ranging from $15 to over $100, from their rooms or belongings. Despite notifying the Resident Council President and various staff, including the Administrator, DON, and Social Service Director, residents did not receive updates or reimbursement. The Social Service Director confirmed forwarding statements to the Administrator but was unaware of any investigation outcomes. The Administrator acknowledged the reports but did not reimburse residents, citing uncertainty about the exact amounts. Residents affected had varying cognitive abilities and medical conditions, and the facility did not follow its policy to protect resident property.
Two residents, both cognitively intact and with significant medical histories, reported being treated in a demeaning, intimidating, and disrespectful manner by an LPN, including raised voices, sarcastic remarks, and rough tones during medication administration. Staff interviews confirmed the LPN also used vulgar language and insults toward coworkers, contributing to an environment lacking in dignity and respect for both residents and staff.
The facility failed to inform or involve residents and their representatives when it revoked the privileges of two attending physicians and a nurse practitioner, resulting in multiple residents losing access to their chosen medical providers. Residents and families were not given adequate notification, explanation, or meaningful choice regarding their ongoing care, and some felt pressured or threatened during the process. The administration did not attempt to mediate concerns with the outgoing medical staff or communicate changes during resident council or care plan meetings.
A resident with multiple complex medical conditions and moderate cognitive impairment was not informed, nor was their representative, about a facility decision to discontinue external wound care clinic visits and transfer wound care to an in-house nurse practitioner. The facility made this change without providing notification or allowing participation in the decision, despite prior communication with the representative about other care matters. The resident's representative remained unaware of the change and believed the resident was still receiving external wound care.
A resident with significant cognitive impairment and multiple medical conditions returned from a hospital stay without previously ordered interventions, such as an abduction pillow and nutritional supplement, being reinstated. Facility staff did not contact the provider to clarify whether these interventions should be resumed, and there was no policy guiding the review or transcription of readmission orders, resulting in a lapse in continuity of care.
Deficient Food Storage, Labeling, and Handling Practices Observed in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage and handling practices during two kitchen inspections. In Refrigerator #1, several trays of prepared salads, bowls of pudding, fruit, and staff food were found without date labels, and some items were in direct contact with each other. Additional items, such as blueberry cobbler, fruit cocktail, and prefilled whipped topping, were also missing required labeling or were past their use-by dates. In Refrigerator #3, raw chicken tenders were left exposed with the lid off, cheese slices were left open and dried out, and produce such as strawberries and oranges were found to be spoiled or overly ripe. Dry storage bins for sugar, rice, and cornmeal were left uncovered, and an opened bag of grits was not securely closed. The Food Service Supervisor acknowledged these deficiencies and stated that it was his responsibility to ensure food safety. Further observations revealed unsanitary handling of ready-to-eat foods by kitchen staff. Staff members were seen using gloved hands to pick up and move bread and noodles directly on residents' plates, contrary to food safety protocols. An opened bottle of lemon juice requiring refrigeration was found improperly stored on a shelf. Interviews with staff confirmed awareness of proper food handling procedures, but lapses were attributed to forgetfulness. The Administrator acknowledged the issues with food storage, labeling, and unsanitary handling, emphasizing that all kitchen staff are responsible for maintaining food quality and sanitation.
Failure to Timely Address Resident Grievances Regarding Housekeeping
Penalty
Summary
The facility failed to review and resolve multiple resident grievances regarding housekeeping in a timely and effective manner, as evidenced by ongoing complaints documented in three consecutive months of Resident Council meeting minutes. Residents repeatedly expressed concerns about unclean floors, unemptied trash, and a lack of general housekeeping, particularly on weekends when no dedicated housekeeping staff were assigned. These grievances were raised during council meetings but did not receive a response or resolution from facility management. Specific residents reported that their rooms were left unclean throughout the weekend, with one resident managing persistent odors and unclean conditions due to accidents until staff returned on Monday. Interviews with the Housekeeping Manager and Administrator confirmed awareness of the complaints and acknowledged that staffing shortages, especially on weekends, contributed to the unresolved issues. Despite being aware of the ongoing concerns, the facility did not take prompt or effective action to address the grievances, resulting in persistent environmental issues for the residents.
Failure to Report Allegations of Verbal Abuse and Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure timely reporting of allegations of verbal abuse and misappropriation of resident property as required by federal regulations and its own policies. Specifically, staff did not report allegations of verbal abuse involving two residents, despite both the residents and a witness describing the LPN's behavior as loud, demeaning, and intimidating. The LPN admitted to speaking loudly, and a CNA corroborated the negative and vulgar conduct. The incident was not reported to the Director of Nursing, and the DON confirmed she was unaware of the situation, stating that staff are required to report such allegations and that the nurse would have been removed from resident care pending investigation if reported. Additionally, the facility failed to report multiple allegations of theft of resident funds involving five residents to the State Agency. The Administrator acknowledged that several residents had reported missing money but stated that reimbursement was not provided due to lack of verification of the amounts lost. The Administrator also admitted to not knowing that such incidents needed to be reported to the State Agency. The facility's policy requires immediate reporting of abuse and misappropriation allegations to appropriate authorities, but this protocol was not followed in these cases.
Unattended and Unlocked Wound Care Cart with Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored to prevent unauthorized access. On one of the survey days, a wound care cart located in the 200 Hall was observed to be unlocked and unattended for fifteen minutes, with wound cleanser left unsecured on top of the cart. The cart contained medications such as Nystatin, Santyl, Dakin's solution, and other wound care agents. The cart was only locked after a registered nurse returned, placed the unsecured cleanser inside, and secured the cart. Interviews with the registered nurse and the Director of Nursing confirmed that the cart should have been locked at all times when not in use, as per facility policy. The nurse explained that the keypad locking mechanism was malfunctioning, requiring manual locking, and admitted to forgetting to lock the cart after use. The Director of Nursing and the Administrator both acknowledged the expectation that all treatment carts remain locked and that no medications or supplies should be left unsecured.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse by staff, as evidenced by multiple interviews and record reviews involving two cognitively intact residents. One resident reported that a night shift LPN raised her voice, spoke in a demeaning and intimidating manner, and responded sarcastically when questioned about a new medication, making the resident feel degraded, afraid, and intimidated. The resident's roommate confirmed the LPN's loud and intimidating behavior, and another resident described the nurse as using a rough tone, talking down to residents, and using her authority to intimidate. Both residents expressed that the nurse's conduct was inappropriate and made them feel uncomfortable and fearful. Staff interviews corroborated the residents' accounts, with a CNA reporting that the same LPN was extremely negative, loud, vulgar, and insulting to both staff and residents during the shift in question. The CNA recalled the LPN using profane language towards staff and described her as intimidating. The facility scheduler confirmed that the CNA, who rarely complains, reported verbal abuse by the LPN, including cursing and name-calling. The Director of Nursing stated she had not been informed of the incident but noted a second, unrelated complaint about the same LPN's verbal abuse towards staff on the same night. The facility's policy prohibits abuse, neglect, and exploitation, but the events described indicate a failure to implement these protections.
Failure to Protect Residents from Misappropriation of Funds
Penalty
Summary
The facility failed to protect residents from misappropriation of their funds and did not implement corrective action or reimburse residents after multiple reports of missing money. Several residents reported to the Resident Council President and staff that their personal funds, ranging from $15 to over $100, were stolen from their rooms or personal belongings. Despite these reports, residents did not receive updates on the status of their complaints or any reimbursement for their losses. The facility's policy requires protection of resident property, but this was not followed in these cases. Interviews with residents revealed that they had reported the thefts to various staff members, including the Administrator, DON, Social Service Director, and security personnel. However, the residents consistently stated that no follow-up or resolution was provided. The Social Service Director confirmed that she collected statements and forwarded them to the Administrator, but was unaware of any investigation outcomes or reimbursements. The Administrator acknowledged the reports of stolen money but stated that, in his view, the facility was not obliged to reimburse residents unless the exact amounts could be confirmed. The affected residents had varying degrees of cognitive function, with some being cognitively intact and others having moderate impairment. Their medical histories included conditions such as heart disease, heart failure, anxiety disorder, anemia, and hemiplegia. The lack of action and communication from the facility left residents feeling unsafe, discouraged, and financially vulnerable, as their reports of missing funds were not addressed or resolved.
Failure to Ensure Residents' Right to Dignity and Respect by Nursing Staff
Penalty
Summary
Licensed nursing staff failed to treat residents with dignity and respect, as evidenced by multiple reports from both residents and staff. One resident reported that a night shift LPN raised her voice, spoke in a demeaning and intimidating tone, and argued with her about taking a newly prescribed medication that was causing stomach upset. The resident described feeling talked down to, afraid, degraded, and intimidated. The resident's roommate confirmed the LPN's loud and intimidating behavior, describing the interaction as uncalled for and rude. Another resident, who is a former CNA, also reported that the same nurse spoke to residents in a rough tone, used her authority to intimidate, and treated them like children, which she deemed inappropriate for the setting. Staff interviews further corroborated these concerns. A CNA reported that the LPN had spoken to her in a demeaning and vulgar manner, including the use of profanity and insults, leading the CNA to avoid working with the nurse. The facility scheduler confirmed that the CNA, who rarely complains, reported being verbally abused by the LPN during a night shift. Both the Administrator and the DON acknowledged that all residents have the right to be treated with dignity and respect. The residents involved were cognitively intact, as indicated by their BIMS scores, and had medical histories including hemiplegia, hemiparesis following cerebral infarction, and acute on chronic systolic congestive heart failure.
Failure to Honor Residents' Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor residents' rights to choose their attending physician by unilaterally revoking the privileges of two attending physicians and a nurse practitioner without informing or involving the affected residents or their representatives in the decision-making process. Despite facility policies supporting residents' rights to select their own physicians, the administration made administrative changes to the medical staff, including the revocation of privileges for the existing medical team, without providing cause or attempting to mediate any concerns with the providers. Residents and their responsible parties were not given adequate notification or explanation regarding the changes, nor were they offered meaningful choices regarding their ongoing medical care. Multiple residents and their representatives reported that they were either not notified at all or were only informed after the changes had already taken effect. Some residents learned of the changes through indirect means, such as being told by other staff or after inquiring themselves. Several residents expressed satisfaction with their previous physicians and nurse practitioner, stating that they would have preferred to continue care with them. In some cases, responsible parties felt pressured or manipulated into signing forms to change physicians, and some expressed fear of retribution or involuntary discharge if they did not comply with the facility's requests. The report documents that the facility did not attempt to address or mediate any concerns with the outgoing medical staff, nor did it provide residents or their representatives with options or involve them in the decision to change providers. The administration instructed staff to refer all questions about the changes to the administrator or assistant-in-training, and did not communicate the changes during resident council or care plan meetings. The lack of communication and involvement left residents and their families confused, upset, and concerned about continuity and quality of care.
Failure to Inform Resident and Representative of Changes in Wound Care Provider
Penalty
Summary
The facility failed to ensure that a resident and their representative were informed of, and allowed to participate in, treatment decisions, specifically regarding changes in wound care providers and treatment locations. Despite facility policies requiring residents and their representatives to be notified about the practitioners responsible for their care and to be given the opportunity to choose providers, the facility made a unilateral decision to discontinue sending residents to an external wound care clinic and instead transferred wound care to an in-house nurse practitioner. This change was made without notifying the affected resident or their power of attorney, even though the facility had previously communicated with the representative about other care matters. The administrator confirmed that no written or verbal notifications were provided to residents or their representatives about the change in provider or treatment location. The resident involved had multiple complex medical conditions, including osteomyelitis, peripheral vascular disease, diabetes, dementia, and multiple unhealed pressure ulcers. The resident was dependent on staff for most activities of daily living and had moderate cognitive impairment, requiring a representative to make medical decisions. The resident's representative was not informed of the discontinuation of care by the external wound care clinic, the change in medical director, or the revocation of attending physician privileges, and believed the resident was still receiving care at the clinic. The medical director also reported being unable to monitor the resident's wounds for several weeks due to the facility's decision, despite ongoing concerns about infection and the need for potential intravenous antibiotic therapy.
Failure to Clarify and Resume Pre-Hospital Interventions After Readmission
Penalty
Summary
The facility failed to notify the provider to clarify missing orders for previously established interventions after a resident returned from the hospital. Prior to hospital transfer, the resident had orders for an abduction pillow and a nutritional supplement, but these were not mentioned in the hospital's After Visit Summary upon readmission. The facility did not contact the provider to determine if these interventions should be resumed, resulting in the interventions not being reinstated. Interviews with the ADON, DON, and the Administrator confirmed that no clarification was sought regarding the continuation of these interventions, and there was no policy in place for reviewing or transcribing readmission orders to address such situations. The resident involved was admitted with multiple diagnoses, including malignant neoplasm of the cervix, protein-calorie malnutrition, vitamin D deficiency, and bilateral femoral neck fractures. The resident was cognitively impaired, with a BIMS score of 1, and was dependent for transfers and non-ambulatory. The lapse in continuity of care occurred because the facility did not verify whether to continue previously established interventions following the resident's return from the hospital.
Some of the Latest Corrective Actions taken by Facilities in Mississippi
- Reviewed and updated the facility assessment, adding revised shift/unit staffing levels and a contingency plan for staffing emergencies (L - F0838 - MS) (K - F0725 - MS) (K - F0600 - MS)
- Revised policies on Abuse & Neglect, medication administration/errors, flu-outbreak management, isolation precautions, QAPI, and Infection Preventionist duties and in-serviced all staff on the updates (L - F0838 - MS) (K - F0725 - MS) (K - F0600 - MS)
- Conducted mandatory in-service training for nurses on medication-administration procedures, including use of the emergency drug kit and immediate reporting of missed doses (L - F0838 - MS) (K - F0725 - MS) (K - F0600 - MS)
- Provided facility-wide education on flu-outbreak surveillance, isolation precautions, and ongoing resident/staff symptom monitoring (L - F0838 - MS) (K - F0725 - MS) (K - F0600 - MS)
- Established daily reviews of staffing coverage against the facility assessment and daily clinical meetings to monitor missed medications (L - F0838 - MS) (K - F0725 - MS) (K - F0600 - MS)
Failure to Maintain Adequate Staffing Assessment and Contingency Plan During Influenza Outbreak
Penalty
Summary
The facility failed to ensure its facility-wide assessment contained the required details regarding staffing needs by shift and by unit, and did not maintain an actionable contingency plan for staffing emergencies. The assessment only included hours per resident day (HPRD) rather than specifying the number of licensed nurses and CNAs needed per shift and per unit. During an influenza outbreak, the facility did not update the assessment or contingency plan to address the increased risk and staffing needs, and administrative staff were used to assist with care when a nurse called in sick, but no agency staff were used and no formal process was in place to secure additional coverage. On the night in question, only one nurse was responsible for 58 residents from midnight until 7 AM, resulting in missed medications and inadequate monitoring for residents on one unit. The administrator and DON were aware of the staffing shortage and attempted to contact other nurses, including those at sister facilities, but were unable to secure additional coverage. The administrator assisted at the nursing station, but the facility's contingency plan did not provide clear procedures for securing coverage during emergencies or staff call-offs, and no updates were made to the plan following the incident. The facility did not identify the influenza outbreak when three residents tested positive, did not initiate droplet precautions, notify the health department, provide timely antiviral treatment, or maintain outbreak surveillance and staff illness tracking. The facility also failed to use its QAPI program to identify and correct system failures in infection control and staffing during the outbreak. These failures resulted in the facility being unprepared for staff absences during the influenza outbreak, placing all residents at risk for serious illness, harm, impairment, or death.
Removal Plan
- The Administrator held an emergency Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse, and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for QAPI for any changes needed and as re-education in policy.
- The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies.
- Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building.
- The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist.
- Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies.
- The Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications.
- The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
- The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
- Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in-service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
- The Administrator reviewed policy on QAPI plan and policy for re-education purposes and to review new policy. The QAPI plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up QAPI meeting.
- The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
- The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
- The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
- The Administrator notified the Mississippi Department of Health of the flu outbreak.
- The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.
Failure to Provide Sufficient Nursing and Nurse Aide Staffing During Influenza Outbreak
Penalty
Summary
The facility failed to provide sufficient licensed nurse and nurse aide coverage to meet resident needs, particularly during an influenza outbreak. On one unit, only one Registered Nurse was responsible for all 58 residents in the facility overnight, resulting in missed medications and lack of resident monitoring. The facility's staffing records showed that only one nurse was present from approximately midnight to 7:00 AM, and there was no documentation of efforts to secure additional coverage after a nurse called in sick. Interviews with staff confirmed that the on-call nurse was also ill and unable to work, and that administrative staff, who were not licensed nurses, attempted to assist but could not provide necessary care or medication administration. Residents reported not receiving their scheduled morning medications, including pain medications, and staff confirmed that medication passes were missed. In addition to the nursing shortage, the facility failed to provide sufficient nurse aide staffing to ensure that residents received scheduled showers and baths. Documentation revealed that several residents missed multiple scheduled showers or baths over the course of a month, and both residents and staff reported that there were not enough CNAs to complete all required bathing care. Interviews with CNAs and LPNs indicated that staffing levels were inadequate to meet resident needs, especially on shower days, and that management was aware of the ongoing problem. The Director of Nursing and Administrator both acknowledged that CNA staffing shortages and high resident acuity were persistent issues, particularly on weekends. The facility's policies and facility assessment did not provide adequate detail on staffing needs by shift and by unit, nor did they include a specific contingency plan for staffing emergencies. The facility lacked a current policy for contingency or emergency staffing and did not have a documented process for on-call procedures in the event of staff call-ins. During the influenza outbreak, the facility did not activate its emergency plan or utilize agency staff, and no updates were made to the contingency plan following the incident. The Medical Director was not informed of the staffing shortage during the outbreak and stated that additional staff should have been provided given the increase in resident acuity.
Removal Plan
- The Administrator held an emergency Quality Assurance and Performance Improvement meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for Quality Assurance and Performance Improvement for any changes needed and as re-education in policy. The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies. Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building. The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist. Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies.
- The Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications.
- The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
- The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
- Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in-service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
- The Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The Quality Assurance and Performance Improvement plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up Quality Assurance and Performance Improvement meeting.
- The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
- The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
- The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
- The Administrator notified the Mississippi Department of Health of the flu outbreak.
- The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.
Failure to Administer Medications and Provide Supervision During Influenza Outbreak
Penalty
Summary
The facility failed to protect residents from neglect by not ensuring prescribed medications were administered, failing to notify physicians of missed medications, and not providing appropriate supervision and monitoring during a period of increased resident illness and high acuity related to an influenza outbreak. On the night in question, only one RN was present in the facility from approximately midnight to 7:00 AM, responsible for all 58 residents, including those on two separate units. This staffing shortage resulted from a nurse calling in sick, with no documented attempts by facility leadership to secure replacement coverage, and no nurse being assigned to one of the units. The facility's daily assignment sheets and timecards confirmed that only one licensed nurse was present during this critical period, and the facility's contingency plan for staffing emergencies was found to be inadequate and lacking actionable processes. Multiple residents did not receive their scheduled medications, including pain medications, antibiotics, and other essential treatments. For example, one resident did not receive morning doses of hydrocodone, Lasix, or gabapentin; another missed doses of pregabalin, sodium chloride, and other medications; and a resident on IV antibiotics did not receive scheduled doses. Medication Administration Records and controlled drug logs confirmed these omissions, and interviews with residents and staff corroborated that medications were missed and not administered as ordered. Additionally, the facility failed to notify physicians of these missed medications, and the medical director was unaware of the situation until informed by surveyors. During the influenza outbreak, the facility did not identify the outbreak in a timely manner, failed to initiate droplet precautions, did not notify the health department, and did not provide timely antiviral treatment or maintain outbreak surveillance and staff illness tracking. The facility's policies required adequate staffing and oversight, but these were not followed, and the Quality Assurance and Performance Improvement (QAPI) program did not identify or correct the systemic failures in infection control and staffing. Interviews with staff and leadership confirmed a lack of clear direction regarding nursing coverage responsibilities, insufficient oversight, and a lack of timely physician notification for missed medications, placing all residents at risk during the outbreak.
Removal Plan
- The Administrator held an emergency Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse, and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions included in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions, reviewing policy for QAPI for any changes needed and as re-education in policy, reviewing and updating facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies, completing a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building, in-servicing the Infection Preventionist on roles and responsibilities, and reviewing and updating policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and expectations of the Infection Preventionist. Staff were in-serviced with new policies.
- The Administrator notified the Medical Director of missed medications during the QAPI meeting. All missed medications were reviewed with the Medical Director. No new orders were given. No adverse reactions were noted due to missed medications.
- The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
- The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
- Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in-service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
- The Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The QAPI plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up QAPI meeting.
- The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
- The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
- The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
- The Administrator notified the Mississippi Department of Health of the flu outbreak.
- The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.
Resident Left Unattended in Facility Transport Van
Penalty
Summary
A facility failed to ensure a resident's right to be free from neglect when a resident was left unattended and strapped in a facility transport van for approximately two hours after returning from a medical appointment. The Transportation Aide (TA) parked the van at the facility and went inside without removing the resident, who was unable to ambulate or call for help. The resident remained in the van, exposed to heat and without access to hydration, care, or supervision, until staff located her after her representative inquired about her whereabouts. The resident, who had diagnoses including Paroxysmal Atrial Fibrillation and Chronic Kidney Disease and a moderate cognitive impairment, was found to be hot, thirsty, weak, and emotionally distressed upon being discovered. She had urinated on herself, her face was puffy, her eyes were red, and her hands were swollen. The resident expressed fear and anxiety during the incident, stating she thought she might die and was afraid she would be left on the bus overnight. Staff interviews confirmed the resident's physical and emotional distress upon her return to her room. The TA admitted to being distracted by work-related concerns and failing to ensure the resident was safely returned to her room. The facility's policy required that residents be protected from neglect, and staff interviews, including those with the DON and Administrator, confirmed that the resident's care and safety needs were not met during the two-hour period she was left unattended in the van. The incident was determined to be Immediate Jeopardy and Substandard Quality of Care due to the facility's failure to provide necessary care and supervision.
Removal Plan
- Hold a Quality Assurance (QA) meeting.
- Provide in-services with all staff.
- Complete a health assessment and monitoring for Resident #1.
- Notify reporting officials of the incident.
- Monitor through the QA program.
- Director of Nursing and Assistant Director of Nursing utilize End-of-Route Witness Audit Form to monitor both the vehicle walk-throughs and the completion of the End-of-Route Two-Person Checklist.
- Conduct monitoring.
Failure to Supervise Aggressive Resident Results in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents involving a resident with known aggressive behaviors. Upon admission, the resident had documented diagnoses of Schizoaffective Disorder, Bipolar Type, Schizophrenia, and Suicidal Ideation, and exhibited severe cognitive impairment. Despite these known risks, the facility did not implement appropriate psychiatric care, enhanced supervision, or reassign vulnerable roommates. The resident repeatedly refused medications, threatened staff, and engaged in escalating aggressive and combative behaviors, including chasing and cornering staff, barricading rooms, and making death threats. Multiple staff interviews revealed that the resident's behaviors were not consistently managed or reported. Nurses and LPNs observed the resident threatening to harm others, barricading himself and others in rooms, and requiring police intervention on more than one occasion. Staff acknowledged that affected roommates and nearby residents were not relocated or provided with additional protection, and interventions were limited to verbal reassurance. Residents reported feeling unsafe, unable to sleep, and fearful of being harmed, with one resident avoiding their room and another being trapped and crying due to fear. Record reviews documented a pattern of aggressive incidents, including threats to kill staff and residents, inappropriate sexual comments, attempts to scald others, and physical altercations requiring emergency services. The facility did not remove environmental risks, such as unsecured fire extinguishers and movable beds, which the resident used to barricade doors. The lack of adequate supervision, failure to implement effective interventions, and insufficient response to escalating behaviors resulted in Immediate Jeopardy and Substandard Quality of Care, directly affecting multiple residents.
Removal Plan
- The Director of Nursing started an all-staff in-service on Abuse/Neglect policy with emphasis on resident psychosocial harm and abuse de-escalation of behavioral episodes and an investigation of psychosocial harm.
- Affected residents care plans were updated to reflect trauma informed care by the Care Plan team.
- The Regional Director in-serviced the Administrator and the Director of Nursing regarding Abuse/Neglect, Investigations of Psychosocial Harm, Behavioral Services, De-escalations and Accidents and Hazards.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: Regional Director, Executive Director, Director of Nursing, MDS Nurse, Business Development Services, Social Services Director, Assistant Director of Nursing, Environmental Services, Maintenance Director and Infection Prevention Nurse.
- Residents #2, #3 and #4's Care Plans were updated to include Trauma Centered care.
- Education was initiated with all facility staff by the Director of Nursing on Abuse and Neglect Policy with emphasis on Resident's psychosocial harm, de-escalation of behavioral episodes and investigation of psychosocial harm. Staff will be educated prior to accepting assignment.
- Education was conducted with the Executive Director and Director of Nursing by the Regional Director of Clinical Services on investigation post behavioral episodes for psychosocial harm of Residents.
- Interview with current Residents with a Brief Interview Mental Status (BIMS) or 10 or greater was conducted by the Social Services Director, Social Services Assistant, and the Assistant Director of Nursing to assess for any psychosocial harm or Incident of trauma.
- Quality Assurance Performance Improvement (QAPI) Committee met. Abuse Neglect Policy, Behavioral Health Policy and Accidents and Supervision Policy was reviewed with no changes made.
- Once Resident #1 exited facility the fire extinguisher was mounted back securely, and the beds were placed with wheels locked to remove barricade risk.
- Resident #1 will not return to the facility until cleared and appropriate safeguards are in place.
Failure to Protect Residents from Abuse and Neglect Due to Inadequate Supervision of Aggressive Resident
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and intimidation by admitting and retaining a resident with known aggressive and violent behaviors without implementing adequate supervision, behavioral interventions, or protective measures for other residents. The resident in question had diagnoses including Schizoaffective Disorder, Bipolar Type, Schizophrenia, and Suicidal Ideation, and was assessed as having severe cognitive impairment. Despite repeated incidents of aggression, threats, and physical intimidation towards both staff and other residents, the facility did not provide necessary psychiatric intervention or relocate vulnerable roommates to ensure their safety. Multiple residents were directly affected by the aggressive behaviors. One resident, who shared an adjoining room, reported being repeatedly threatened and verbally abused at night, leading to fear and inability to sleep. Another roommate experienced threats and was once barricaded in the room by the aggressive resident, preventing access to medication and staff intervention. A third resident, located across the hall, expressed fear and avoided leaving her room when the aggressive resident was present and yelling in the halls. Staff interviews confirmed that these behaviors were ongoing and that no formal interventions, such as increased supervision or room changes, were implemented to protect the affected residents. Progress notes and staff interviews documented a pattern of escalating behaviors, including refusal of medication, threats to kill staff and residents, inappropriate sexual comments, physical aggression, and property damage. The aggressive resident repeatedly barricaded doors, threatened others, and required police and emergency medical intervention on multiple occasions. Despite these incidents, the facility did not implement effective interventions or provide adequate supervision, resulting in an unsafe environment and placing multiple residents at risk for serious injury, harm, impairment, or death.
Removal Plan
- Resident #1 was transported to the local emergency department and subsequently to an inpatient behavioral health facility; Resident #1 remains in inpatient behavioral health facility.
- Once Resident #1 exited the facility, the fire extinguisher was mounted back securely, and the beds were placed with wheels locked to remove barricade risk.
- The Executive Director interviewed the resident that was barricaded in the room with Resident #1 to assess for fear or trauma.
- The facility issued an emergency notification of discharge to Resident #1's family and began searching for alternative placement; Resident #1 will not return until cleared and appropriate safeguards are in place.
- Education was initiated with all facility staff by the Director of Nursing on Abuse and Neglect Policy, with emphasis on resident psychosocial harm, de-escalation of behavioral episodes, and investigation of psychosocial harm. Staff will be educated prior to accepting assignment.
- Education was conducted with the Executive Director and Director of Nursing by the Regional Director of Clinical Services on investigation post behavioral episodes for psychosocial harm of residents.
- Interviews with current residents with a BIMS of 10 or greater were conducted by the Social Services Director, Social Services Assistant, and the Assistant Director of Nursing to assess for any psychosocial harm or incident of trauma.
- Residents #2, #3, and #4's care plans were updated to include trauma-centered care.
- The Quality Assurance Performance Improvement (QAPI) Committee met to review the incident and policies.
- Abuse Neglect Policy, Behavioral Health Policy, and Accidents and Supervision Policy were reviewed.
- The Director of Nursing started an all-staff in-service on Abuse/Neglect policy with emphasis on resident psychosocial harm, abuse de-escalation of behavioral episodes, and investigation of psychosocial harm.
- Affected residents' care plans were updated to reflect trauma-informed care by the Care Plan team.
- The Regional Director in-serviced the Administrator and the Director of Nursing regarding Abuse/Neglect, Investigations of Psychosocial Harm, Behavioral Services, De-escalations, and Accidents and Hazards.
- An Emergency Quality Assurance Committee was held with key facility staff in attendance.
Elopement Due to Inadequate Supervision and Resident Identification
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with a BIMS score of 6 indicating severe cognitive impairment, was able to exit the facility without authorization. The resident, who had diagnoses including Wernicke's encephalopathy and vascular dementia, was last seen in the main lobby by her assigned CNA before the CNA left for a scheduled lunch break. Upon the CNA's return, the resident was missing from both the common area and her room, prompting immediate notification to the RN/MDS nurse and the initiation of a facility-wide search. The investigation revealed that the resident followed a dietary aide out of the front door as the aide was leaving at the end of his shift. The dietary aide, who did not recognize the individual as a resident due to her street clothes and purse, assumed she was a visitor and allowed her to exit behind him. The aide later observed the resident attempting to enter a parked vehicle in the lot before returning to the facility entrance. The resident remained outside for approximately 35 minutes before being found knocking on the front door by another CNA during the search. At the time she was found, the resident was appropriately dressed, carrying her purse, and did not display signs of distress or injury. Staff interviews confirmed that the resident was care-planned as an elopement risk, wore a yellow identification bracelet, and was listed in the facility's wander book. Despite these precautions, the dietary aide was unaware of her status and allowed her to exit. The facility is located near a four-lane highway and industrial complex, with no fencing or restricted barriers between the grounds and the surrounding area. The failure to provide adequate supervision and to ensure staff could properly identify residents resulted in the resident's unauthorized exit and exposure to potential harm.
Removal Plan
- CNA#1 reported Resident #1 missing to MDS Nurse #1, who called Code W (elopement), and all staff began a search of the facility and perimeter.
- Resident #1 was brought inside with no signs of distress after being found outside.
- Administrator was notified by MDS Nurse about the incident.
- MDS Nurse completed a body audit with no signs or symptoms of injury.
- MDS Nurse completed a head count of all current residents in the facility.
- MDS Nurse notified Resident #1's representative of the incident.
- Medical Director was notified of Resident #1's incident and no new orders were given.
- Administrator arrived at the facility and checked that all doors were functioning properly.
- Administrator interviewed all employees and any residents that had interactions with Resident #1 prior to the incident.
- Administrator began in-service for all employees on elopement policy and procedures; all staff would be in-serviced before returning to their next shift.
- Administrator reported incident to State Agency.
- An emergency Quality Assurance & Performance Improvement (QAPI) committee meeting was held to discuss incident, actions taken, and further interventions.
- Social Services Director spoke with Resident #1 and noted no psychosocial harm due to incident.
- Maintenance Director conducted a quality check of all doors to make sure they were operating as expected and door alarms were added to all of the doors.
- Regional Director of Operations interviewed Resident #1 and Resident #2 for any details they remember about the incident.
- Education of elopement policy and procedures with dietary staff, including Dietary Aide #1.
- Wander assessments were completed on all active residents in the facility by DON, RN #1, LPN #1, and Medical Records LPN.
- Maintenance Director began elopement drills for all shifts.
- A follow up QAPI committee meeting was held by Administrator to discuss that all interventions were in place.
- Maintenance will conduct a quality check of all doors, an elopement drill on each shift and put alarms on each of the doors.
- Administrative nurses completed wander assessments on all current residents, update care plans and wander books accordingly; completed a 100 percent audit of care plans; completed 100 percent audit of wander books located at both nurse's stations.
- Social services would interview Resident #1 for any psychosocial harm.
- Administrative staff would in-service all employees on elopement policy and procedures before their next shift.
- Elopement drills on all shifts and one elopement drill per week for four weeks on alternating shifts and one per month for six months on alternating shifts.
- Person-centered in-services will be completed with all staff for any new residents identified as an elopement risk or any current residents who are newly identified as an elopement risk.
- Incident was reported to Attorney General's office by Administrator.
Failure to Prevent Elopement Due to Inadequate Supervision and Staff Error
Penalty
Summary
A newly admitted respite resident with diagnoses of restlessness, agitation, dementia, senile degeneration of the brain, and a history of exit-seeking behaviors and falls was assisted to exit the facility by staff. The resident was outside unsupervised for approximately twenty-five minutes until a staff member observed her lying on the ground next to the iron fence that encircled the facility premises, about 375 feet from the facility entrance. The resident had been admitted earlier that day and was only oriented to self, with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The facility's policy required staff to know the location of their residents and to report or intervene if a resident attempted to leave the premises. However, the receptionist, who was not aware of the new admission and had not verified the resident's identity, unlocked the door and escorted the resident outside without determining if she was safe to exit. The resident then wandered the grounds unsupervised, eventually being found by staff who were leaving their shift. The staff who found her did not initially recognize her as a resident and had to ask questions to confirm her status before summoning the DON and assisting her back into the facility. Interviews and record reviews confirmed that the receptionist had received training on security and elopement risks but failed to follow procedures. The incident was not immediately recognized by the assigned unit manager, who had assessed the resident as not at risk for elopement based on incomplete information. The resident's responsible party and primary healthcare provider were notified after the incident, and the resident was not injured. The facility's failure to provide adequate supervision and a secure environment contributed to the resident's elopement and placed all residents with wandering or exit-seeking behaviors at risk.
Removal Plan
- A second at risk for elopement assessment completed for Resident #9
- Resident #9's Instant care plan and Kardex were updated
- One-on-one supervision orders received, and monitoring implemented
- Resident #9's Responsible Party (RP) and Primary Healthcare Provider were notified of the incident with safe wandering device bracelet orders received with bracelet applied on Resident #9 with orders for nurses to check placement and functioning every shift
- Head to toe body audit was conducted for Resident #9
- Nursing staff completed 100% head count of all residents not signed out on pass with all residents accounted for
- Employee corrective counseling completed with former Receptionist (Category 1 offence, employment terminated)
- 100% At risk for elopement evaluations completed on all residents
- 100% in-service training started for all staff prior to working on - Elopement/Wandering, Abuse/Neglect, Behaviors, Adequate monitoring, Supervision
- Safe wandering devices for all residents wearing them are checked every shift for placement and functioning
- Elopement Drills were conducted on all shifts
- 100% audit of elopement books completed
- All doors checked for proper functioning
- Security specialist contractor visited and checked doors for functioning
- Quality Assurance (QA) Meeting attended by all key personnel, which included but not limited to Executive Director, Director of Nurses, Infection Preventionist and Medical Director was held with root cause analysis conducted and interdisciplinary team developed strategy to prevent future elopement incidents
- Resident #9 to remain on 1:1 until discharge from facility; discharged
- Resident photos will be taken at the time of admission, regardless of elopement risk assessment results, and posted at the receptionist desk
- One-on-one monitoring/supervision of Resident #9 through discharge
- Admissions Coordinator to monitor the communication board in the reception office to ensure the board's accuracy and currently with all new admissions' photographs posted
- Continued elopement assessments of all newly admitted residents at the time of admission by nursing staff
- Continued monitoring of positioning and functioning of safe wandering devices worn by residents at risk of elopement every shift by nursing staff
- Continued daily monitoring of the safe wandering system functionality by the maintenance director
- Review of and development of care plans for all newly admitted residents with family/resident to evaluate for history of wandering/elopement for three (3) months with monitoring results and corrective actions reviewed at QA meetings for three (3) months
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