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)
Some of the Latest Corrective Actions taken by Facilities in Mississippi
Environmental Controls & Physical Security
- Installed keypad locks on kitchen entrance doors to restrict unauthorized resident egress (J - F0689 - MS)
- Began installation of wander guard alarm system on the kitchen loading-dock door for continuous exit monitoring (J - F0689 - MS)
- Posted reminder signage on all exit doors instructing staff and visitors to prevent residents from leaving unaccompanied (J - F0689 - MS) (J - F0610 - MS) (J - F0600 - MS)
Staff, Visitor, and Family Education & Monitoring
- Conducted facility-wide in-services covering exit-door procedures, residents’ rights, abuse prevention, and elopement response (J - F0689 - MS)
- In-serviced Social Services staff on promptly initiating elopement precautions for residents exhibiting exit-seeking behaviors (J - F0689 - MS) (J - F0610 - MS) (J - F0600 - MS)
- Educated front-desk personnel to obtain coverage before leaving the reception area to maintain supervision of the main entrance (J - F0689 - MS) (J - F0610 - MS) (J - F0600 - MS)
- Distributed letters to resident representatives requesting notification of staff when residents express desire to leave and advising caution with entry/exit doors (J - F0689 - MS) (J - F0689 - MS) (J - F0610 - MS) (J - F0600 - MS)
- Established weekday nursing review of 24-hour progress notes to detect exit-seeking behavior and ensure timely interventions (J - F0689 - MS)
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as an elopement and wandering risk, resulting in the resident exiting the facility unsupervised. The resident, who had a diagnosis of Schizophrenia and severe cognitive impairment as indicated by a BIMS score of 4, was last seen in the dining room by staff. Despite being equipped with a wander guard bracelet, the resident was able to leave the facility through a kitchen door that was not equipped with a wander guard alert system, unlike other facility exits. The door had a keypad lock, but it was accessible from the dining area and not properly secured to prevent resident exit. Staff did not immediately notice the resident's absence. The resident's walker was left in the dining room, and staff initially assumed the resident had returned to his room. It was only after a phone call from the resident's family and subsequent checks that staff realized the resident was missing. A facility-wide elopement alert was then announced, and staff began searching the premises and surrounding area. The resident was located approximately one mile from the facility, having crossed a busy four-lane highway, and was returned after being unsupervised for about two hours. Interviews with staff and family confirmed that the resident had a history of exit-seeking behavior and had previously expressed a desire to go home. Staff had observed the resident attempting to open exit doors on multiple occasions. The facility's policy required staff to report any resident attempting to leave or suspected of being missing, but in this instance, the resident was able to leave undetected due to the lack of a wander guard system on the kitchen door and insufficient supervision in the dining area.
Removal Plan
- RN #2 performed a head-to-toe assessment with the resident's daughter, Executive Director, and DON present. There were no visible physical injuries.
- A 100% audit of all Wander/Elopement Risk residents were assessed for placement and proper functioning with no adverse findings.
- All the facility's entrance and exit door's alarm systems were checked. All the alarms were functioning properly.
- Resident #1 checked for wander guard placement and properly working. His wander guard was intact and working properly.
- Head-to-toe assessment of Resident #1 completed by the Unit B Manager and DON. There were no negative findings.
- Resident #1 was interviewed by the Unit B Manager. No negative statements were made by the resident.
- Upon Resident #1's return he was placed on 1:1 location monitoring x (times) 72 hours then tapered down to every 15 minutes then every 30 minutes then every hour. The Unit Manager, DON, and Social Services will determine when the resident may be removed from 1:1. The resident was placed on 24 hours charting for the nurses to document and notifying the MD/NP of any significant changes in the resident physical or mental status.
- A keypad lock was placed on the kitchen entrance door in the dining room by the Housekeeping Supervisor. The Housekeeping Supervisor replaced the old door handle on the kitchen door next to Unit-B with a keypad. The code will be given to dietary workers and key staff.
- The Maintenance Supervisor contacted Systronic Alarms Systems on installing a wander guard alarm on the kitchen door leading to the loading dock. A representative from the company will be at the facility.
- Resident #1 was moved closer to the nurses station. He moved from B 118P to B 108P. The Elopement Wander guard book reviewed. The Elopement Book was correct. A 100% check of the Wander/Elopement Risk were assessed for placement and proper functioning.
- The Dietary Workers on shift during the time of the incident received 1:1 Educational In-Services on Exit Doors in the kitchen and written corrective counseling by the Executive Director.
- Educational In-services for the facility's staff conducted by the Staff Development/Executive Director were initiated and included: a) Exit Doors in the kitchen b) Resident's Rights c) Abuse Prevention and Reporting d) Abuse and Neglect e) Residents expression to go home f) Missing Resident/Elopement.
- The Unit B Manager re-schedule Resident #1's eye appointment. Resident's appointment is scheduled as a follow-up consult visit to rule out retinal vein occlusion with macula edema to the left eye.
- Resident #1's care plan and pain assessment up-dated. Social Services Director preformed a Trauma Screen.
- The facility prepared a formal letter to mail to each resident's representative. The letter requests that during visits, if the resident expresses wish to leave the facility or return home, the family should inform nurse management, the Executive Director, or Social Services.
- We had a Family Meeting with Resident #1's daughter. The daughter did not express any concerns about her father's care or safety with the facility.
- Nursing will review 24 hour progress notes on the following week day and/or Monday following the weekend for any resident's voicing wanting to go home or exhibits exit seeking behavior to ensure proper intervention are in place.
- A QAPI was implemented with an emergency QA meeting reviewing Resident #1's incident.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Identification
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent the elopement of a resident who had documented new wandering and exit-seeking behaviors for at least a week. The resident, who had diagnoses including bipolar disorder, anxiety, schizophrenia, a history of falls, and was assessed as at risk for falls and requiring supervision for walking, exited the facility unnoticed and was found sitting unsupervised in a staff member's car in the parking lot. The resident had been observed packing belongings, expressing confusion, and making statements about leaving, but these behaviors were not identified as exit-seeking or elopement risk by staff. Despite multiple staff members observing the resident's behavioral changes, including repeated trips to the front entrance and packing bags, the care plan was not updated to reflect the new risk, and no interventions such as wander management devices or increased supervision were implemented prior to the elopement. Documentation of the resident's change in behavior was reported to the primary healthcare provider, who ordered a urinalysis, but the facility did not recognize or address the increased risk of elopement. Staff interviews revealed a lack of awareness and action regarding the resident's behaviors, and no incident report was completed after the resident exited the facility. Additionally, facility policies and procedures were not followed, as evidenced by the absence of an updated care plan, missing elopement binders at the nurses' station, and lack of head counts or elopement drills following the incident. The front entrance could be opened with a code, and the receptionist, who was aware of the resident's behaviors, left the desk unattended without ensuring coverage. The facility did not report the incident to the State Agency in a timely manner, and there was no thorough investigation or immediate implementation of elopement precautions for the resident prior to the event.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.
Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to initiate a thorough investigation into an allegation of neglect and an incident of elopement involving one of six sampled residents. On the specified date, a resident exited the facility unsupervised and was found sitting in a staff member's car in the facility parking lot. The resident had left the building unnoticed by staff during a shift change and was able to access an area adjacent to a busy four-lane boulevard. The staff member who discovered the resident escorted her back into the facility and notified the appropriate personnel, including the Executive Director and the Director of Nursing Services. Despite the incident, there was no documentation of the elopement in the facility's accident/incident log, and no incident report was completed. Multiple staff members, including LPNs and the Unit Manager, confirmed that they were aware of the resident's unsupervised exit but did not participate in any investigation or initiate missing resident procedures. No head count of residents was conducted, and the event was not reported to the State Agency as required. The Executive Director stated that the incident was not considered an elopement because the resident claimed she was waiting for her brother, and therefore, no report was made to any agencies. The resident involved had a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, but her most recent assessment indicated no cognitive impairment and no documented wandering or exit-seeking behaviors. The facility's policies required immediate investigation and reporting of such incidents, but these procedures were not followed. The failure to conduct a thorough investigation and report the incident placed the resident and others at risk, as identified by the State Agency, which cited the facility for failing to meet regulatory requirements regarding the investigation and prevention of alleged violations.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who cover the receptionist area, the receptionist was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social Service Assistants and Medical Director. The IP nurse was present by phone.
Failure to Prevent Resident Elopement Due to Lack of Timely Intervention
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not implementing measures to prevent elopement for a resident who had recently begun exhibiting exit-seeking behaviors. The resident, who had diagnoses including bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, began displaying new behaviors such as packing belongings and waiting at the front door, believing her family was coming to get her. Despite these documented behaviors, staff did not update the resident's care plan or implement additional supervision or wander management interventions prior to the incident. On the day of the incident, the resident exited the facility unnoticed and unsupervised. She was found approximately fifteen minutes later by a CNA, sitting in the passenger seat of the CNA's car in the facility parking lot, which was located near a busy four-lane boulevard. Staff were unaware of the resident's absence until she was brought back inside. There was no incident report completed at the time, and no head count or missing resident protocol was initiated following the event. Interviews with staff confirmed that the resident's care plan had not been updated to reflect her new exit-seeking behaviors, and that elopement drills or additional supervision had not been implemented. The facility's policy required identification and intervention in situations where neglect was more likely to occur, including increased supervision for residents at risk. However, despite multiple staff members observing and documenting the resident's exit-seeking behaviors in the days leading up to the incident, no changes were made to her care plan or supervision level. The lack of timely intervention and failure to follow facility policy resulted in the resident being able to leave the facility unsupervised, placing her at risk.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for residents with behavioral changes that verbalize leaving the facility, exit seeking, wandering, and packing belongings should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all residents who were determined to be at risk for elopement to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident #1 to confirm details of the elopement.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and exiting the facility and to notify staff if a resident verbalizes thoughts of leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. All routine staff who cover the receptionist area were also in-serviced.
- A 100% audit of elopement binders was conducted by the Social Service Department to ensure the binders' information was reflective of all residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with key facility leadership and the Medical Director to review the incident and corrective actions.
Failure to Timely Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse within the required two-hour timeframe to the appropriate authorities. The incident involved a resident who was found by a CNA on top of another resident in bed, with his hand inside her incontinence brief, performing jabbing motions. Both residents were clothed at the time, but the CNA observed the inappropriate behavior and called for assistance. The male resident became violent when staff attempted to remove him, striking a staff member in the process. Upon assessment, the female resident was found to have scratches and bruising on her upper legs and labia, as well as additional bruising and discoloration on her thigh and eyebrow. Facility records show that the incident was reported internally to the nursing home administrator and social worker shortly after it occurred. However, the administrator did not recognize the event as sexual abuse and did not report it to the State Department within the required two-hour window. Instead, the administrator believed there was a 24-hour reporting window and notified the State Department the following day. The incident was also not reported to local law enforcement immediately, as the administrator did not initially view it as a crime. The facility's policy, in accordance with the Elder Justice Act, requires that any suspicion of a crime involving serious bodily injury to a resident be reported immediately, but no later than two hours after the suspicion arises. The failure to report the incident in a timely manner placed the affected resident and others at risk for further harm. The survey agency identified this as Immediate Jeopardy and Substandard Quality of Care, citing the facility for not adhering to regulatory requirements for reporting alleged violations.
Removal Plan
- Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2.
- Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident.
- A CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit.
- LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted.
- Staff Development Specialist (SDS) performed a full body audit on Resident #56. The findings were red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas.
- Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received.
- NHA notified the Ombudsman of the incident.
- LMSW notified the Responsible Party (RP) of the incident.
- NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident #16 and continuing supervision.
- RP of Resident #16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement.
- LMSW verified that a CNA was placed outside Resident #16's room.
- NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone.
- A follow-up weekly body audit completed on Resident #56. No additional injuries identified.
- Primary physician notified of Resident #16 acceptance at behavioral health facility.
- NHA notified the Attorney General's Office of the incident.
- NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov.
- Resident #16 was transferred to a behavioral health facility.
- NHA notified local law enforcement of the incident.
- Local law enforcement on-site.
- Incident report received from local law enforcement.
- The Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse.
- The Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced.
- The IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced.
- No staff, including the Director of Nursing, will be allowed to work until they are in-serviced.
- An Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM.
- A Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1.
- The Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors.
Failure to Prevent Sexual Abuse and Inadequate Supervision of Resident with Known Sexual Behaviors
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in a serious incident involving two residents on the Special Care Unit. One resident with a history of severe cognitive impairment and Alzheimer's Disease was found in her bed with another resident on top of her, his hand inside her incontinence brief, performing jabbing motions. Staff observed scratches, bruising, and edema on the resident's labia and thigh, as well as bruising to her eyebrow. The incident was witnessed by multiple CNAs and a nurse, who reported that the male resident became violent and struck a staff member when they attempted to intervene. Prior to this event, the male resident had a documented history of sexually inappropriate behaviors, including making explicit comments, grabbing staff, and attempting to touch staff inappropriately. These behaviors had been ongoing since at least November of the previous year, with multiple entries in his medical record noting sexual comments and physical actions toward staff. Despite these documented behaviors, the facility did not implement effective interventions to prevent further sexual behaviors or protect other residents from potential harm. Staff interviews confirmed that the male resident frequently made sexual statements and gestures toward both staff and other residents, and had previously grabbed staff inappropriately. On the day of the incident, he was able to access another resident's room and commit sexual abuse, indicating a lack of adequate supervision and preventive measures. The facility did not assess other residents for signs of abuse immediately following the incident, and no body audits were performed on other residents at that time. The failure to address the ongoing sexually inappropriate behaviors and to implement sufficient interventions led to an incident that caused and was likely to cause serious harm.
Removal Plan
- Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2.
- Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident.
- A CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit.
- LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted.
- Staff Development Specialist (SDS) performed a full body audit on Resident #56. The findings included red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of a quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas.
- Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received.
- NHA notified the Ombudsman of the incident.
- LMSW notified Resident #56's Responsible Party (RP) of the incident.
- NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event. to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident # 16 and continuing supervision.
- RP of Resident # 16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement.
- LMSW verified that a CNA was placed outside Resident #16's room.
- NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone.
- A follow-up weekly body audit completed on Resident # 56. No additional injuries identified.
- Primary physician notified of Resident # 16 acceptance at behavioral health facility.
- NHA notified the Attorney General's Office of the incident.
- NHA sent an email reporting the incident to the MSDH via email to facilityreportedincidents@msdh.ms.gov.
- Resident # 16 was transferred to a behavioral health facility.
- NHA notified local law enforcement of the incident.
- Local law enforcement on-site.
- Incident report received from local law enforcement.
- The Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse.
- The Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced.
- The IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced.
- No staff, including the Director of Nursing, will be allowed to work until in serviced.
- An Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM.
- A Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1.
- The Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors.
Latest Citations in Mississippi
A resident with a history of falls and moderate cognitive impairment suffered a head laceration requiring ER treatment after staff removed bed rails without a safety assessment or alternative interventions. The resident rolled out of bed during care, and staff confirmed no individualized assessment or additional safety measures were implemented following the removal of the rails.
Surveyors observed that the facility did not properly store or monitor food items, resulting in overly ripe produce with visible spoilage, expired condiments, and failure to follow manufacturer storage instructions. The Dietary Manager and Administrator acknowledged that food safety procedures were not followed, leading to the presence of spoiled and improperly stored food in the kitchen.
The facility did not ensure that all direct care staffing hours, including those worked by salaried nursing leadership, were accurately recorded and submitted in the PBJ data to CMS. The DON and ADON worked on the floor during periods of low staffing but did not clock in or out, resulting in their hours not being included in the PBJ submission for the quarter. This led to the facility triggering for excessively low weekend staffing.
Residents repeatedly raised concerns about the lack of condiments during meals and delayed call light response times, with some reporting waits of up to 30 minutes and having to call 911 for assistance. Staff confirmed that condiments were unavailable due to delivery issues and that call light responsiveness was an ongoing problem, especially during meal service and overnight shifts. Despite these grievances being documented and reported through appropriate channels, the facility did not resolve them promptly as required by policy.
Surveyors identified inaccurate MDS coding for two residents, including one who was discharged home but coded as discharged to a hospital, and another whose MDS indicated anticoagulant use despite no such medication being ordered or administered. Staff interviews and record reviews confirmed these errors, reflecting a pattern of deficiency in MDS accuracy.
During a shift change, only one CNA was present on three resident halls while multiple call lights went unanswered for about 30 minutes, with nurses remaining at the nurse's station and unaware that CNAs had left the floor. A resident reported waiting for help for 30 to 40 minutes. Staff interviews confirmed that CNAs often leave without notifying nurses, walking rounds are not conducted, and staffing shortages are ongoing.
A resident's care plan was not revised to reflect their improved transfer abilities after therapy discharge, resulting in continued documentation for a mechanical lift that was no longer needed. Staff confirmed the resident required only minimal assistance, but the care plan remained outdated and inconsistent with current assessments.
Three rooms were found with exposed sheetrock, chipped paint, and exposed metal, compromising the comfort and homelike environment for residents. The Maintenance Supervisor confirmed the need for repairs and noted that repair requests were often communicated verbally rather than documented in work orders.
A resident with a below-knee amputation was transported by van without being secured with the vehicle's safety seat belt, resulting in a fall from the wheelchair onto the van floor. The CNA responsible admitted to not buckling the seat belt, and the facility lacked a policy on accident prevention or van transport. The resident was evaluated at the emergency room and found to have no injuries.
Staff failed to ensure a resident was free from physical restraints when two CNAs wrapped a sheet around the resident's legs and secured it with tape to prevent removal of a brief, without physician order or care plan documentation. The resident, who had severe cognitive impairment, was found with his legs bound, and a red area was noted on his leg that resolved within an hour. The intervention was not authorized and violated facility policy.
Failure to Assess and Implement Safety Measures After Bed Rail Removal
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision and equipment to prevent accidents for one of four sampled residents. Staff removed the resident's bed rails without conducting a safety assessment, despite documentation indicating a history of falls from bed and a care plan that included the use of partial bed rails at all times. No assessment was completed to determine if the resident would be safe without the bed rails, and no alternative safety interventions were implemented at the time of removal. The resident, who had diagnoses including chronic obstructive pulmonary disease, muscle wasting and atrophy, repeated falls, and required assistance with personal care, was moderately cognitively impaired. During care, the resident rolled out of bed after the bed rails had been removed, sustaining a head laceration that required emergency room treatment, including x-rays and stitches. Staff interviews confirmed that the resident previously used the bed rails for assistance with turning and that their removal was based on a facility-wide policy change, not on an individualized assessment. Observations and interviews revealed that the resident was being assisted by a CNA at the time of the fall, who turned the resident and then reached for supplies, during which the resident rolled off the bed. The incident resulted in a significant injury, and it was confirmed by the DON and other staff that no side rail assessment was completed at the time of removal and no other safety measures were put in place to prevent injury after the bed rails were taken off.
Failure to Store and Maintain Food in Accordance with Professional Standards
Penalty
Summary
During a kitchen observation, surveyors identified that the facility failed to store food and maintain food quality in accordance with professional standards for food safety. Specifically, refrigerator #3 contained a plastic storage container with 14 overly ripe cucumbers that had a white slimy rind, were soft and pliable, and had liquid accumulated at the bottom. In the pantry, there was an opened bottle of yellow mustard past its 'best if used by' date, an opened gallon-sized bottle of soy sauce that was not refrigerated as instructed by the manufacturer, 19 overly ripe oranges with green and white bio-growth on the rind, and an overly ripe apple with a brown soft spot and exposed interior. These findings were acknowledged by the Dietary Manager, who confirmed that she had not examined the produce that day as intended and recognized the risks associated with having overly ripe food in the kitchen. The Dietary Manager stated that it is her responsibility to ensure food is not expired and is stored properly, and the Administrator confirmed that monitoring food supplies for proper storage and spoilage is the DM's responsibility. The facility's policy requires all perishable foods to be maintained at a temperature of 41 degrees Fahrenheit or below, and the manufacturer's instructions for certain items were not followed. The observations and interviews confirmed that the facility did not adhere to its own food storage policies and professional standards, resulting in the presence of spoiled and improperly stored food items in the kitchen.
Failure to Accurately Report Direct Care Staffing in PBJ Submission
Penalty
Summary
The facility failed to ensure that its Payroll Based Journal (PBJ) submissions to CMS accurately reflected direct care staffing hours, as required. Review of CASPER reporting data showed the facility triggered for excessively low weekend staffing for one of four quarters. Examination of monthly schedules indicated that both the Director of Nursing (DON) and Assistant Director of Nursing (ADON), who are salaried employees, worked as supervisors and on the floor during weekends in the quarter in question. However, they did not clock in or out during this period, and their work hours were only documented on assignment sheets, not in the PBJ data submitted to CMS. Interviews with facility staff revealed that the DON and ADON only began clocking in and out within the last two weeks, and prior to that, there was no verifiable or auditable record of their hours worked on the floor. The staffing coordinator was responsible for correcting staff punches and updating codes when staff worked outside their usual roles, but the PBJ data sent to the corporate office did not include the DON and ADON's hours for the quarter in question. The Administrator and Director of Payroll were unaware that the facility had triggered for low weekend staffing, and the PBJ submission was accepted by CMS despite the incomplete data.
Failure to Resolve Resident Grievances on Condiments and Call Light Response
Penalty
Summary
The facility failed to promptly resolve grievances raised by residents regarding the lack of condiments during meals and delayed call light response times. Resident Council meeting minutes from October and November 2024 documented ongoing concerns about the absence of basic condiments such as salt, pepper, and butter. Observations confirmed that residents were served meals, including baked potatoes and roast beef, without condiments, and no salt or pepper shakers were present in the dining area. Staff interviews revealed that the dietary department had run out of condiments due to a delivery issue, and no alternative arrangements were made to provide these items to residents. Residents also reported significant delays in call light response times, with some stating that it could take up to 20 or 30 minutes for staff to respond, particularly during the overnight shift. Multiple residents described situations where staff would turn off call lights and promise to return but failed to do so, leading to unmet needs. One resident reported having to call 911 for assistance after her call light was ignored for an extended period. The Ombudsman corroborated these concerns, noting that CNAs were frequently not present or visible on the units during her visits. Interviews with facility staff, including the Social Services Director and Activities Director, confirmed that grievances about food service and call light response times were common and had been documented. However, these grievances were not resolved in a timely manner, as required by facility policy and resident rights regulations. The ongoing nature of these issues, as reported by residents and staff, demonstrated a failure to address and resolve resident concerns promptly.
Inaccurate MDS Coding for Discharge Status and Medication Administration
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in deficiencies related to discharge status and medication administration. For one resident admitted with a fractured femur, the clinical record and discharge documentation indicated the resident was discharged home, but the Discharge MDS was incorrectly coded as a discharge to a short-term general hospital. The Social Services Director acknowledged making an incorrect entry, and both the Registered Nurse and Director of Nursing confirmed that it is the responsibility of the discipline completing each section of the MDS to ensure accuracy before submission. For another resident admitted with a seizure diagnosis, the Quarterly MDS indicated the resident was taking an anticoagulant, but a review of physician's orders and the Medication Administration Record for the relevant period showed no anticoagulant was ordered or administered. The error was confirmed by a Registered Nurse after reviewing the records, and the Administrator acknowledged the discrepancies in MDS coding for both discharge status and medication administration. These findings were based on record reviews, staff interviews, and facility policy review, and represent a pattern of deficiency as the same tag was cited on the previous annual recertification survey.
Insufficient Staffing During Shift Change Leads to Unanswered Call Lights
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs during a shift change on three of six resident halls. During the transition from day to evening shift, only one CNA was present on the floor while three nurses remained at the nurse's station, and five resident call lights were observed activated for approximately 30 minutes without response. Multiple staff interviews confirmed that CNAs left the floor without notifying nurses, and one CNA had been sent home on administrative leave, further reducing available staff. Nurses at the station were unaware that the CNAs had left and did not respond to the call lights, resulting in residents' needs going unmet for an extended period. A resident was heard calling for help, stating her call light had been on for 30 to 40 minutes and she needed assistance. Staff interviews revealed that it was common for CNAs to leave the floor before the next shift arrived and that walking rounds were not conducted to communicate care needs to the oncoming shift. The Assistant Director of Nursing and other nursing staff were unaware of the absence of CNAs during this period, and administrative staff confirmed ongoing staffing shortages and efforts to recruit additional staff. The facility's staffing policy requires adequate staffing based on resident acuity and needs, but this was not maintained during the observed shift change.
Failure to Update Care Plan After Change in Transfer Needs
Penalty
Summary
The facility failed to revise the care plan for a resident who no longer required the use of a mechanical lift for transfers. Despite the resident's progress in therapy, which resulted in discharge at contact guard assist level and no longer needing a lift, the care plan continued to list interventions for a Hoyer Total Lift and related equipment. Multiple staff interviews confirmed that the resident was independent with transfers, requiring only assistance from one staff member, and that there were no current orders for a mechanical lift. However, the care plan had not been updated to reflect these changes, and the last lift evaluation on file was outdated. The deficiency was identified through observations, interviews, and record reviews, which revealed that the care plan did not accurately reflect the resident's current needs and abilities. The resident, who was cognitively intact and had a history of seizures, anxiety disorder, delusional disorders, and traumatic brain injury, was able to transfer with minimal assistance and did not require a lift. Facility staff, including nursing and therapy, confirmed the discrepancy between the resident's current status and the care plan documentation.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a comfortable, homelike environment in three rooms on the North Unit, as required by its Resident Rights & Quality of Life Policy. Observations by a State Agent revealed exposed sheetrock surrounding the air conditioner in one room, and additional rooms were found to have exposed wall areas near doors and air conditioners, chipped paint, and exposed metal on the bottom corners of walls. The Maintenance Supervisor confirmed that these areas were in need of repair and attributed some of the damage to moving a bed. A review of maintenance work orders showed that no formal repair requests had been documented for these rooms, and the Maintenance Supervisor acknowledged that many repair needs are communicated verbally rather than being formally recorded.
Failure to Secure Resident with Safety Seat Belt During Van Transport
Penalty
Summary
A deficiency occurred when a resident, who had an acquired absence of the left leg below the knee, was being transported by van to a physician's appointment. During the trip, the Certified Nursing Assistant (CNA) responsible for the transport failed to secure the resident with the vehicle-supplied safety seat belt, although the wheelchair itself was secured to the van. The CNA later admitted that the seat belt was not buckled around the resident. As a result, the resident slid out of the wheelchair and fell onto the floor of the van. Emergency Medical Services (EMS) were contacted, and the resident was transported to the emergency room, where it was determined that no injuries had occurred and no treatment was required. Further review revealed that the facility did not have a policy on accident prevention or van transport. Staff interviews confirmed that the expectation was for the safety seat belt to be used during transport, and both the Administrator and Director of Nursing acknowledged that the failure to apply the seat belt could result in injuries. The lack of a specific policy and the omission of the safety measure directly contributed to the incident.
Unauthorized Use of Physical Restraint with Sheet and Tape
Penalty
Summary
Facility staff failed to ensure a resident was free from the use of physical restraints when two CNAs wrapped a sheet around the resident's legs and secured it with tape to prevent the resident from removing his brief and smearing feces. The resident, who had severe cognitive impairment due to Parkinson's Disease, was found by an LPN tugging at the sheet, with his legs bound together by tape over the sheet. The intervention was not ordered by a physician, not included in the care plan, and there was no documentation of assessment or approval for the use of a physical restraint. The facility's policy defined physical restraints as any device or material that the resident cannot remove easily, and specifically prohibited practices such as tucking sheets to restrict movement. Interviews confirmed that the CNAs used the sheet and tape without authorization, and the DON and Administrator acknowledged the intervention was a violation of policy. The resident's arms and feet were not restricted, and a red area was noted on the leg, which resolved within an hour. There was no evidence of injury directly caused by the restraint, and the incident was not classified as abuse.