Citations in Mississippi Y

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident who was newly admitted with dementia, delusional disorder, hallucinations, and a documented history of wandering. The resident’s admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and identified a history of wandering, while functional assessment documented that the resident could ambulate independently for 150 feet. The admission history and physical from the community setting described dementia with agitation and psychosis, aggressive behaviors and irritability related to attempts to cross the street, and agitation when unable to perform desired activities such as going across the road. The physician had previously discussed safety issues with the family and recommended additional door locks at home to prevent wandering and leaving the house. Upon admission, the facility had a physician order to monitor wandering and elopement for 14 days and an active order to monitor behavior each shift for anxiety, restlessness, and pacing. On the morning following admission, the resident was observed by an LPN at approximately 10:35–10:40 a.m. sitting on the side of the bed and had been seen walking in the hallway and to the nurse’s station earlier in the day. Around 11:30–11:40 a.m., when staff were preparing lunch, a CNA was unable to locate the resident in the room, dining room, or therapy area and notified nursing staff that the resident might be missing. A brief search inside the facility was conducted before the DON was notified and a missing resident code was called overhead. Staff then initiated a broader search of the building and surrounding outside areas after learning the identity of the missing resident. The Administrator later reviewed security camera footage and determined that a dietary aide had assisted the resident with the front entrance door. The dietary aide reported that she had seen the resident at the front door, did not know who he was, and entered the numeric code into the keypad to disengage the lock, allowing the resident to exit the building unaccompanied and unsupervised. The facility’s elopement and wandering policy stated that residents at risk for elopement were to receive adequate supervision, that interventions were to be added to the care plan and communicated to staff, and that door locks/alarms and a systematic approach to monitoring and managing residents at risk were to be used. At the time of the incident, the facility relied on staff-held numeric codes for exit doors and did not have a two-part safe wandering system with resident-worn monitors and corresponding door monitors. The resident was ultimately located by the maintenance technician approximately 0.5 miles from the facility, sitting on the steps of a local business, and was returned to the facility. Interviews with staff confirmed the sequence of events and the lack of recognition of the resident’s identity and risk status at the exit door. The Administrator confirmed that the dietary aide had not checked with nursing staff before entering the door code and allowing the resident to leave. The maintenance technician stated that, regardless of the route taken, the resident would have had to cross two of the busiest streets in town to reach the location where he was found. At the time he was located, the resident’s clothing and shoes were clean and dry, and staff assessments upon return noted no injuries or pain. The facility’s failure to ensure that a resident with known severe cognitive impairment and a history of wandering was adequately supervised, and to prevent an untrained staff member from facilitating his exit through a secured door, resulted in the resident leaving the facility unnoticed and unsupervised.

Removal Plan

• Initiated Code [NAME] (missing resident) and began facility-wide search when Resident #1 could not be located.
• Notified the Administrator immediately via Code [NAME].
• Notified the physician.
• Notified the resident representative.
• Completed a head count to ensure all other residents were accounted for.
• Expanded the search throughout the facility.
• Expanded the search outside the facility and assigned maintenance staff to search by vehicle.
• Located Resident #1 off-site and returned the resident safely to the facility.
• Physician assessed and evaluated Resident #1 upon return; no injury noted.
• LPN performed a full body audit upon return; no injury noted.
• RN performed a pain assessment upon return; no pain verbalized.
• Placed Resident #1 on one-on-one (1:1) monitoring upon return.
• Reassessed Resident #1 for wander and elopement risk (moderate risk).
• Updated Resident #1 care plan to include one-on-one (1:1) monitoring.
• Verified all doors were functioning properly.
• Audited residents to identify risk for wandering and elopement and identified additional residents at risk who continued to be monitored.
• Reported the event to the Mississippi State Department of Health Hotline.
• Reported the event on the Attorney General Medicaid Fraud Site.
• Reviewed the Wander and Elopement Binder to ensure updated risk assessments and current photos for residents at risk.
• Updated colored signage instructing staff to check with nursing before allowing anyone out the door.
• Suspended the Dietary Aide pending investigation and terminated employment.
• Held an emergency QAPI meeting.
• Completed facility-wide education/in-services on the Elopement and Wandering Residents Policy, Code [NAME] Policy, identifying residents at risk for elopement, and resident identification protocols.
• Conducted elopement drills on each shift.
• Implemented ongoing monitoring of staff competency/knowledge regarding wandering risk and safety awareness using scheduled knowledge testing.
• Implemented monitoring of the Elopement Binder to ensure each at-risk resident has a current photograph and up-to-date risk assessment.
• Implemented monitoring of residents at risk for wandering/elopement to ensure alert band placement, with planned replacement by safe wandering system bracelet placement upon installation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its own “Homelike Environment” policy, which states that residents are to be provided with a clean, sanitary, and orderly environment. During surveyor observations and interviews, one resident’s room contained a urine collection device on the bathroom floor, a hole in the drywall above the light, and six cracked linoleum tiles near the entrance. The resident reported being at the facility for therapy and expressed dissatisfaction with housekeeping services. The Housekeeping Supervisor acknowledged that blackish-brown discolored areas on the floor required stripping and scraping, confirmed that baseboards in both affected residents’ rooms were dust-covered, and stated that easily removable substances should have been cleaned by housekeeping, while missing plaster and broken tiles required maintenance. In another resident’s room, surveyors observed a three-inch piece of the bathroom door frame and the threshold between the room and bathroom missing, a dust-covered wall-mounted hand sanitizer dispenser, multiple brown pinpoint spots and streaks on the wall below the dispenser, discolored and dusty baseboards with residue that wiped off easily, and a floor area behind the door with brown to black discoloration in the corner. The exposed plumbing pipes under the bathroom sink were only partially covered with polyfoam and had a dark brown substance on them, and there was a six-inch by one-inch area of missing drywall in the bathroom. This resident, who was cognitively intact and admitted with diabetes and hypertension, stated that housekeepers came daily but did not do a thorough job, that she had limited ability to put belongings away, and that staff were not conscientious about putting her items away, resulting in clothing and other items scattered on all surfaces. Both residents involved were cognitively intact per their MDS BIMS scores, and the Administrator acknowledged awareness of housekeeping and maintenance needs in resident rooms.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide palatable food at an appetizing and safe temperature to residents receiving in-room meal service. Facility policy titled “Assisting the Resident with In-Room Meals” (revised 2013) directed staff to check that hot foods are hot. Two cognitively intact residents, both with diabetes and hypertension and one with additional acute kidney failure, reported that meals served in their rooms were usually cold or not hot enough to be enjoyable. One resident stated staff told her that her meals were not hot because she was the last served due to her room location, and the other resident reported that her meals were never served hot but that she continued to eat them without replacement or reheating. On a kitchen observation, the cook prepared meals while a dietary aide placed plates on trays and covered them with insulated dome covers but did not use the insulated heat-keeper bases/underliners. Nine of 25 meals had dome covers that did not fully cover the plates, leaving food not completely covered to conserve heat, including the meal for one of the affected residents. Six of 25 plates were covered only by heat-keeper bases instead of dome covers, again including a meal for one of the affected residents. During interviews, the dietary aide and dietary supervisor could not explain why heat-keeper bases were used instead of dome covers for some meals and acknowledged there were not enough heat-keeper bases for all residents receiving in-room meals. The Administrator stated she did not know why insulated bases were not being used and had not been informed of any shortage of insulated components.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a resident’s right to be treated with dignity and respect. Facility policy on Resident Rights and Dignity Management states that each resident is to be treated with respect and dignity in a manner that maintains or enhances quality of life and recognizes individuality. Despite this policy, video footage and interviews confirmed that a CNA spoke to a resident in a rude tone and told her to “shut up” and “hush your mouth” when she was asking for assistance to use the restroom. Resident #1, who had an admission date of 03/13/20 and diagnoses including Type 2 diabetes mellitus and unspecified sequelae of cerebral infarction, had a BIMS score of 15 on a recent MDS, indicating no cognitive deficits. On the date of the incident, she pressed her call light for help to go to the bathroom, then wheeled herself into the hallway when assistance was not immediately provided. She was described by staff and herself as impatient, impulsive, and often demanding, frequently pressing her call light and going into the hall to seek help, particularly for toileting, which required a two-person assist with a lift. According to the Administrator’s review of video footage and interviews with the resident, ADON, and CNA, the resident was calling out in the hallway for help to the restroom when the CNA, who was not assigned to her that day, approached and responded to her in a rude manner. The CNA admitted that the resident was “mouthing off,” and he told her to “shut up” and to “hush her mouth,” acknowledging that this was unprofessional and that he should have walked away and allowed another staff member to assist. The ADON confirmed that, although the resident could be demanding and could provoke staff anger, staff were still required to treat her with dignity and respect at all times, and that the CNA’s behavior toward the resident did not meet this standard.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident with known exit-seeking behaviors, resulting in the resident leaving the building and remaining outside unsupervised in cold weather. The resident had a diagnosis that included unspecified dementia and was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 3. Earlier assessments identified the resident as high risk for wandering on 6/24/25, low risk on 11/7/25, and again high risk on 12/31/25. A wander bracelet ordered in June 2025 for dementia and exit-seeking behaviors was discontinued on 10/28/25. On 12/8/25, a Social Services Progress Note documented that the resident was agitated, sitting in the lobby doorway, yelling that he wanted to go home, tapping on the door, and requiring redirection by nursing staff. The Social Worker later confirmed that these were exit-seeking behaviors and acknowledged that additional interventions such as increased monitoring and a wandering assessment should have been implemented but were not. On 12/30/25, staff documented in the Plan of Care Response History at 11:18 AM that the resident exhibited behavioral symptoms of wandering, noted that these behaviors had occurred previously, and documented that the nurse was notified. Multiple staff interviews confirmed that the resident was known to be exit-seeking on a daily basis and required frequent redirection, yet several CNAs and an LPN assumed the resident already had a wander guard in place when he did not. That evening, the resident was last observed by his assigned CNA watching television in the lobby a little after 7:00 PM. At approximately 7:28 PM, the resident exited the facility through the smokers’ courtyard door. The door was later found by the Maintenance Director to have a malfunction in which sustained pressure on the handle allowed it to open without sounding an alarm. Staff near the courtyard, including a CNA who had been in the breakroom by the exit until about 8:30 PM, reported not hearing any alarm and did not observe anything unusual during that time. The resident was eventually discovered outside when a CNA walking down the hall looked through the courtyard door and saw someone sitting on the patio. The CNA obtained another CNA, who identified the individual as the resident. The resident was brought back inside, and staff observed that he was shivering, rubbing his hands together, and that his hands appeared white or pale. The resident later stated he had gone outside at night because he wanted to meet his girlfriend, walked around the yard, and tried to come back in but found the door locked. He reported sitting outside for a long time before someone opened the door and stated he was shaking and very cold when he returned inside. Vital signs, including body temperature, were not obtained until the following morning at 10:50 AM. The incident occurred when outside temperatures were documented as ranging from 32 to 34 degrees Fahrenheit between 8:00 PM and 9:00 PM. The combination of the resident’s known exit-seeking behavior, lack of enhanced monitoring or wandering interventions after documented behaviors, discontinuation and absence of a wander bracelet, staff assumptions about his elopement protections, and a malfunctioning courtyard door that could be opened without an alarm led to the resident’s unsupervised exit and exposure to cold conditions. The situation was determined by the State Agency to constitute Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) at 42 CFR §483.25(d)(1)(2), Free of Accident Hazards/Supervision/Devices (F689), with an IJ level of scope and severity J beginning on 12/8/25, when the resident began exhibiting exit-seeking behaviors. The IJ and SQC were formally communicated to the facility’s Administrator on 1/12/26 at 4:30 PM, and the IJ template was provided. The IJ level was later reduced from J to D after validation that corrective actions in the facility’s removal plan had been completed, while the facility continued to develop and implement a plan of correction and monitor systemic changes for sustained compliance.

Removal Plan

• CNA found Resident #1 unattended on the courtyard patio, brought him back to the facility, and another CNA took him to his room and alerted the charge nurse.
• RN notified the DON that Resident #1 had exited the building and was found in the courtyard.
• DON notified the Administrator; Administrator instructed 1:1 monitoring for the remainder of the night, instructed DON to call Maintenance to check the door, and instructed that a head count of all residents be done immediately.
• DON notified Maintenance to return to the facility and check the door.
• Resident #1 was assessed by nursing with no ill effects.
• DON instructed a CNA to stay with Resident #1 1:1 for the remainder of the night.
• Maintenance checked the door, found it would open if the handle was compressed longer than 10 seconds, adjusted the bolt to disable the feature so the door would not open, and checked all doors and windows.
• Maintenance notified the DON that the door was corrected, room checks had been done, and all residents were accounted for.
• Resident #1 was assessed as a wandering risk and a signaling device was placed on his wrist for monitoring.
• Social Services updated the Residents at Risk for Elopement in the Elopement Binder.
• Elopement drills were started.
• The Administrator reported the incident to the Mississippi State Department of Health and Licensure.
• The Mississippi Attorney General's Office was notified of the incident.
• An Ad-Hoc QAPI meeting was held to discuss the incident and findings from the State Surveyor.
• The DON conducted an audit of residents at risk for elopement to review wander risk care plans for those residents identified as at risk for wandering.
• In-services began for all staff on elopement, resident rights, proper door functioning, abuse/neglect/reporting, and notifying staff of observed behaviors; staff were not allowed to work until the in-service was completed.
• A revised Ad-Hoc QAPI meeting was held to discuss the incident and findings from the State Surveyor.
• Audit findings for residents at risk for elopement were reviewed with the Administrator, DON, and ADON.
• The Ombudsman was notified.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect residents from neglect in two primary areas: exposure to a known hot-liquid burn hazard and allowing an impaired nurse to remain responsible for resident care and medication administration. On one occasion, a resident with dementia and a severely impaired BIMS score of 03 sustained a burn to the left hip/thigh area when another resident gave him hot coffee, which was then spilled, causing blisters and a new in-house skin issue measuring 7.06 cm by 7.56 cm. The incident report documented that the resident cried out in pain, and subsequent emergency department documentation confirmed the burn was from a coffee spill at the facility. Despite this event, residents continued to have access to hot coffee in the dining room without supervision, temperature controls, or access restrictions for nearly two weeks. The facility also failed to intervene appropriately when an LPN on the night shift was impaired and unable to safely perform nursing duties. Staff statements and camera footage showed the nurse repeatedly falling asleep standing up, leaning over the med cart with eyes closed, crying loudly, moaning, swaying, stumbling, and nearly falling. CNAs reported that residents were calling for their medications, that the nurse fell asleep at the med cart and on the counter in the nurse’s station, and that she repeatedly went to the bathroom for long periods. The DON was notified by another nurse at 1:30 AM that the impaired nurse could not complete the med pass and kept falling asleep, but the impaired nurse remained in the building and responsible for resident care until approximately 3:00–3:30 AM. There was no designated charge nurse on that shift after the scheduled charge nurse called in sick, and no nurse was assigned to supervise staff, coordinate care, or respond to the unsafe condition. Medication administration records and audit reports showed that multiple medications were either not documented as given or were documented late for residents on the impaired nurse’s unit. For four sampled residents, there was no documentation that scheduled evening and bedtime medications were administered on the night in question, including Donepezil for dementia, Crestor, Latanoprost, Novolog, Trazodone, Gabapentin, Duloxetine, Keppra, Lacosamide, and ordered accuchecks. One cognitively intact resident reported being in the dining room, observing that the nurse appeared impaired and unable to safely administer medications, and stated he did not receive his medications and would have been afraid to take them from her. Another cognitively intact resident reported that his medications and blood sugar check were not done and that a CNA told him something was wrong with the nurse. The facility’s own medication administration audit identified 25 residents with missed medications and 5 residents with late medications on that unit during the relevant time frame, and staff confirmed that another LPN pulled medications for the impaired nurse without observing administration, verifying correct resident, or documenting on the MAR, while the impaired nurse retained responsibility and control of narcotic keys. The Administrator acknowledged awareness that the impaired nurse remained on duty until a replacement arrived and that he was not informed of the coffee burn incident until several days after it occurred. He confirmed that, although leadership discussed modifying the coffee service process after he learned of the burn, he did not verify that any changes were implemented or monitored. When surveyors arrived, they were able to obtain hot coffee directly from a dining room machine that was still operational despite signage indicating it was out of service, and the Administrator acknowledged that residents had continued access to hot coffee and that no system had been in place to ensure the discussed intervention was followed. The State Agency determined that these failures to safeguard residents from a known burn hazard and to remove an impaired nurse from resident care created Immediate Jeopardy and substandard quality of care under F600, beginning when residents remained under the care of the impaired nurse.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created to indicate the staff member who tested the temperature of the coffee and the time.
• Coffee temperature logs will be turned into the Administrator daily.
• Training for all staff will be completed prior to their next scheduled shift.
• No staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse.
• Training will include: accidents and supervision including implementing immediate interventions; abuse and neglect reporting and investigation; hot liquids policy; notification of Administrator and DON of unusual occurrences/high risk events and timely notification; charge nurse delegation and duties including assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse and process if assigned charge nurse calls off; posting DON and Administrator phone numbers on the Facility Assignment Grid; requirement to contact DON and Administrator if charge nurse is impaired; updated Facility Assignment Grid to include designated charge nurse; medication administration documentation.
• All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
• Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
• The Facility Assessment was updated by the Administrator to include a contingency plan for absence of supervisory nursing staff and to identify staffing needs by shift and building.
• The facility's Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
• The Scheduler and the Staff Development Nurse were inserviced by the DON on the new Assignment Grid and charge nurse delegation.
• The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
• An emergency Quality Assessment and Assurance Committee meeting was held to review the Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy and to discuss the incident summary, actions taken, training, and monitoring.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving LPN #1.
• LPN #2 was reported to the agency she works for and is not allowed to work at this facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to immediately report allegations of neglect to the State Agency (SA) for two separate events and to implement timely safeguards after serious incidents. In the first event, a resident sustained a burn injury on the left thigh when hot coffee was spilled on the resident’s hip area on 12/31/25 at approximately 3:40 PM. The incident report documented that another resident had given the resident a cup of coffee, which then spilled and caused blistering to the front left thigh/hip area, with wound measurements recorded as approximately 7.06 cm by 7.56 cm and identified as an in-house acquired skin issue. Despite this injury, there was no documentation indicating that interventions were initiated to prevent recurrence or to safeguard other residents who had access to hot coffee. The DON later confirmed that the resident’s burn occurred when another resident provided hot coffee that spilled onto the resident’s leg, and that nursing staff cleansed the area, measured the wound, applied a dressing, and notified the medical provider. However, the DON stated she was not aware of the coffee burn until she returned to the facility on 1/2/26, and confirmed that no immediate interventions were put in place at that time to protect other residents who drink coffee. The coffee machines were not removed; instead, signs were added on 1/6/26 instructing not to use the machines, while the facility began using coffee carafes. On 1/12/26, surveyors observed that a coffee machine in the dining area remained plugged in, operational, and accessible to residents, with hot coffee obtainable without staff assistance or supervision, and no physical barriers in place despite the posted signage. In the second event, the facility failed to immediately report and adequately address an incident involving an impaired LPN responsible for resident care and medication administration on the night shift beginning 12/29/25. The DON received a call at approximately 1:30 AM on 12/30/25 from another LPN reporting that the nurse on Station 2 was unable to complete the medication pass, kept falling asleep, and appeared impaired. Camera footage reviewed by the DON showed the impaired LPN at the nurse’s station and medication cart for about two hours, swaying, stumbling, appearing under the influence, repeatedly falling asleep at the med cart, and being awakened multiple times by CNAs. Statements from CNAs described the LPN falling asleep standing up, crying loudly, going to the bathroom frequently, being “half out of it,” unable to stay awake to pull or pass medications, and failing to administer medications so that residents repeatedly called for their meds. Medication administration audit reports later showed that 25 residents had medications with no administration time documented and 5 residents had medications documented as administered late. The impaired LPN remained on duty and responsible for resident care until approximately 3:00–3:30 AM, when a replacement nurse arrived, and was later discharged from employment. Another LPN who relieved the impaired nurse reported that she was very drowsy, unable to give report, stumbling, and unable to participate in the narcotic count. The Administrator acknowledged awareness of the incident involving the impaired LPN on the 12/29 PM shift and confirmed that the nurse remained on duty for about eight hours until a replacement arrived. The Administrator also acknowledged awareness of the resident’s coffee burn but stated he did not learn of it until six days after it occurred. He reported that he did not consider either the impaired nurse incident or the coffee burn incident to be neglect and therefore did not report them to the SA as alleged violations, despite the facility’s policy requiring prompt reporting of alleged neglect to local, state, and federal agencies.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created and started that indicate the staff member who tested the temperature of the coffee, the time and date.
• Coffee temperature logs will be turned into the Administrator daily.
• Training for all staff prior to their next scheduled shift.
• No staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse.
• Training content includes accidents and supervision including implementing immediate interventions.
• Training content includes abuse and neglect reporting and investigation.
• Training content includes the hot liquids policy.
• Training content includes notification of the Administrator and Director of Nursing (DON) of unusual occurrences, high risk events, and timely notification.
• Training content includes charge nurse delegation and duties to include the assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse.
• If the assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment.
• The DON and Administrator's phone numbers are posted on the Facility Assignment Grid.
• In the event that the charge nurse is impaired, the DON and Administrator will be contacted.
• The Facility Assignment Grid was updated to include assignment for designated charge nurse.
• Training content includes medication administration documentation.
• All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
• The Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
• The Facility Assessment was updated by the Administrator to include a contingency plan for absence of supervisory nursing staff and adequately identified staffing needs by shift and building.
• The facility's Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
• The Scheduler and the Staff Development Nurse were inserviced by the DON on the new Assignment Grid and charge nurse delegation.
• The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
• Emergency Quality Assessment and Assurance Committee Meeting held.
• The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made.
• Summary of incident was discussed with actions taken including training and monitoring.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving LPN #1.
• LPN #2 was reported to the agency that she works for and is not allowed to work at this facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct thorough and timely investigations and to implement safeguards following two separate events involving potential neglect. In the first event, a resident sustained a burn on the left thigh on 12/31/25 at approximately 3:40 PM after another resident gave the resident a cup of hot coffee, which was then spilled, resulting in blistering. Nursing documentation described a new in-house acquired skin issue on the front left trochanter, with a blister measuring 7.06 cm by 7.56 cm. Although staff cleansed the area, measured the wound, applied a dressing, and notified the medical provider, there was no documentation of interventions to prevent recurrence or to safeguard other residents who drink coffee immediately after the incident. The facility did not promptly identify or control the environmental hazard associated with resident access to hot coffee. On 1/12/26 at 7:20 AM, surveyors observed a coffee machine in the dining area that was accessible to residents, labeled out of service but still plugged in and operational. The State Agency was able to obtain hot coffee from the machine without staff assistance or intervention while residents were present in the dining area, and no staff were observed supervising or restricting resident access. No physical barriers were in place to prevent resident use of the machine despite the posted signage. The DON confirmed that no immediate interventions were implemented to safeguard other residents who drink coffee between the time of the burn on 12/31/25 and 1/6/26, and did not describe interviewing residents who drink coffee, reviewing procedures to check coffee temperatures, or assessing environmental risks related to access to hot liquids. In the second event, the facility failed to thoroughly investigate and respond to an impaired nurse who was responsible for resident care and medication administration. On the 12/29/25 7:00 PM–7:00 AM shift, an LPN on Station B appeared impaired, repeatedly fell asleep standing up and at the med cart, cried loudly, and was described by CNAs as half out of it, with legs giving out and requiring a chair placed behind her. Camera footage reviewed by the DON showed the nurse swaying, almost falling, stumbling, staring at the med cart and medication cards for extended periods, and falling asleep at the med cart in the dining room while a resident was present. CNA statements indicated that residents repeatedly called for their medications, that the nurse did not complete the med pass, and that no one received medications for a period, while the nurse remained on duty until approximately 3:00–3:30 AM. Medication Administration Audit Reports for Station B showed 25 residents with medications documented as missed and 5 residents with medications documented as administered late during this time frame. The DON was notified at approximately 1:30 AM by another LPN that the nurse on Station B was unable to complete the med pass and kept falling asleep, but the DON only verbally confirmed with the reporting nurse that residents had received their medications and did not verify this by reviewing Medication Administration Records, Medication Audit Reports, or interviewing residents. The DON did not describe reviewing all events leading up to and following the incident to determine root cause or to prevent recurrence. The Administrator acknowledged awareness of the impaired nurse incident and that the nurse remained on duty until a replacement arrived about eight hours after the start of the shift, but he did not review MARs, Medication Audit Reports, or other documentation to verify whether medications were administered accurately and timely. The facility’s own investigation documents and counseling/discipline report for the impaired LPN noted that the nurse did not complete the med pass and only gave medications to two residents, yet there was no evidence of a comprehensive investigation consistent with the facility’s Abuse Investigation and Reporting policy, which requires thorough review of documentation, medical records, interviews with residents and staff, and review of all events leading up to the alleged incident. The Administrator and DON both confirmed that they did not initiate formal investigations consistent with facility policy for either the coffee burn or the impaired nurse incident. For the coffee burn, the Administrator stated he was not aware of the incident until six days after it occurred and confirmed there were no immediate interventions to safeguard other residents who drink coffee or to assess environmental risks related to access to hot liquids immediately following the incident. For the impaired nurse, the Administrator acknowledged he relied on being told that residents had received their medications and did not independently verify medication administration accuracy or timeliness. These actions and inactions resulted in the facility failing to investigate alleged neglect, failing to prevent further potential neglect, and allowing unsafe conditions to continue for residents with access to hot coffee and for all residents on Station B under the care of the impaired nurse.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created to document the staff member who tested the coffee temperature and the time/date.
• Coffee temperature logs will be turned into the Administrator daily.
• All staff will be trained prior to their next scheduled shift; no staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse.
• Staff training topics include: Accidents and Supervision (including implementing immediate interventions); Abuse and Neglect Reporting and Investigation; Hot Liquids Policy; Notification of Administrator and DON of unusual occurrences/high risk events and timely notification; Charge Nurse Delegation and Duties (including assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse and notification process if assigned charge nurse calls off); Medication Administration Documentation.
• DON and Administrator phone numbers are posted on the Facility Assignment Grid.
• In the event that the charge nurse is impaired, the DON and Administrator will be contacted.
• Facility Assignment Grid was updated to include assignment for designated charge nurse.
• All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
• Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
• Facility Assessment was updated by the Administrator to include a contingency plan for absence of supervisory nursing staff and to identify staffing needs by shift and building.
• Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
• Scheduler and Staff Development Nurse were inserviced by the DON on the new Assignment Grid and Charge Nurse Delegation.
• Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
• Emergency Quality Assessment and Assurance Committee meeting was held with interdisciplinary attendance and the Medical Director present via telephone.
• The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made.
• The incident summary was discussed with actions taken including training and monitoring.
• Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator regarding the incident involving LPN #1.
• LPN #2 was reported to the agency she works for and is not allowed to work at this facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to keep the resident environment free from accident hazards and to provide adequate supervision related to hot liquids, resulting in a resident sustaining a burn from hot coffee. On 12/31/25 at approximately 3:40 PM, a resident with dementia and a severely impaired BIMS score of 03 received hot coffee from another resident in the dining area. The coffee spilled onto the resident’s left thigh/hip area, causing pain and visible blistering. Staff documentation and progress notes identified a new in-house skin issue on the front left trochanter, described as a blister measuring approximately 7.06 cm by 7.56 cm, and the facility’s Medical Director later confirmed this as a second-degree thermal injury from hot coffee. At the time of the incident and in the days following, the facility did not implement environmental controls or supervision to prevent other residents from exposure to the same hot coffee hazard. The facility’s own “Safety of Hot Liquids” policy required hot liquids to be served at safe temperatures, not more than 140°F, with appropriate safety precautions such as staff supervision or assistance and regulation of temperatures for liquids to which residents had direct access. However, review of the facility’s Hot/Cold Holding Temperature Log (coffee logs) showed no coffee temperatures were recorded prior to 1/6/26. Observations on 1/12/26 at 7:20 AM revealed a coffee machine in the dining area that remained plugged in, operational, and accessible to residents, despite being labeled “out of service.” The State Agency was able to obtain hot coffee from this machine without staff assistance or intervention while residents were present and no staff were supervising or restricting access, and there were no physical barriers to prevent resident use. Interviews with facility leadership and staff further demonstrated inaction and lack of timely response to the identified hazard. The DON stated that the incident occurred when one resident provided hot coffee to the cognitively impaired resident, resulting in the burn, and confirmed that she did not become aware of the incident until 1/2/26. She acknowledged that after learning of the burn, no immediate corrective or preventive measures were implemented to reduce the risk of other residents sustaining burns from hot liquids, and that resident access to coffee machines continued without restriction, supervision, or temperature control between 12/31/25 and 1/6/26. The Administrator reported he was not informed of the burn incident until a stand-up meeting on 1/6/26 and confirmed that, even after leadership discussed modifying the coffee service process, he did not verify that any changes were implemented or monitored. A cognitively intact resident reported that residents continued to obtain coffee directly from the machines and that staff did not consistently unplug them, corroborating that residents had ongoing access to hot coffee in violation of the facility’s safety and supervision policies. The facility’s “Safety and Supervision of Residents” policy stated that the environment should be as free from accident hazards as possible, that safety risks and environmental hazards would be identified on an ongoing basis, and that the QAPI/Safety Committee would evaluate hazards and develop strategies to mitigate or remove them. It also required the interdisciplinary team to identify specific accident hazards for individual residents and to implement and communicate targeted interventions, including adequate supervision. Despite these written expectations, the facility did not identify the hot coffee machines as an ongoing environmental hazard after the burn incident, did not promptly analyze or address the risk for other residents, and did not implement or enforce supervision, access restrictions, or temperature regulation for hot coffee until after the State Agency’s on-site observations. Resident #1’s medical record also showed that the burn had been present and under treatment for several days before the family requested an Emergency Department evaluation, where the history documented that the patient had been burned at the nursing home from a coffee spill about a week earlier. This further supports that the burn was recognized and being treated in-house while the underlying environmental hazard—resident access to excessively hot coffee from accessible machines in the dining room—remained unmitigated. The combination of the initial incident, the lack of timely hazard recognition and control, and the continued availability of hot coffee without supervision or temperature monitoring constituted the deficient practice under 42 CFR §483.25(d)(2) related to accidents and hazards.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created to indicate the staff member who tested the temperature of the coffee and the time.
• Coffee temperature logs will be turned into the Administrator daily.
• Training for all staff prior to their next scheduled shift.
• No staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse (Accidents and Supervision including implementing immediate interventions; Abuse and Neglect Reporting and Investigation; Hot Liquids Policy; Notification of Administrator and DON of unusual occurrences/high risk events and timely notification; Charge Nurse Delegation and Duties including assignment of charge nurse; Medication Administration Documentation).
• All residents were evaluated for safety with hot liquids by nursing leadership and RNs.
• Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
• The Facility Assessment was updated to include a contingency plan for absence of supervisory nursing staff and to adequately identify staffing needs by shift and building.
• The facility's Assignment Grid was updated to reflect who the Charge Nurse would be each shift.
• The Scheduler and the Staff Development Nurse were inserviced by the DON on the new Assignment Grid and Charge Nurse Delegation.
• The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
• If the assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment.
• The DON and Administrator's phone numbers are posted on the Facility Assignment Grid.
• In the event that the charge nurse is impaired, the DON and Administrator will be contacted.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
• An emergency Quality Assessment and Assurance Committee meeting was held to review the Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy and discuss incidents/actions taken including training and monitoring.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving an LPN.
• An LPN was reported to the agency that she works for and is not allowed to work at this facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure sufficient licensed nursing supervision and coordination of care when no licensed nurse was designated to serve as charge nurse for the night shift beginning at 7:00 PM on 12/29/25. The scheduled charge nurse called in sick, and the daily staffing schedule showed the supervisor for the 7:00 PM–7:00 AM shift marked out with “vacation” and no replacement charge nurse indicated. As a result, there was no nurse assigned to supervise staff, coordinate care, or respond to unsafe conditions on that shift, despite facility policy requiring a licensed nurse to be designated as charge nurse on each tour of duty. During this unsupervised shift, an LPN assigned to Station B reported being ill, later stating in a counseling/discipline report that they had a temperature of 101 degrees and a blood sugar of 67, and that they did not remember the events. The facility’s investigation and camera footage review showed that this LPN remained on duty from 7:00 PM until approximately 3:00 AM while impaired and unable to safely perform nursing duties. The LPN was observed at the nurse’s station for about two hours, then pushing the medication cart into the hallway, staring at the computer for a long time, swaying and almost falling, stumbling, and appearing to be under the influence of something. The LPN fumbled through the medication cart, pulled medication cards and stared at them for minutes, fell asleep at the medication cart in the dining room with their head resting on the cart, and awoke only when the cart began to roll away. A resident in the dining room witnessed this incident, and nursing assistants repeatedly woke the LPN and placed a chair behind them after they nearly fell while sleeping on the cart. Certified nurse assistants on the unit reported that around 8:00 PM the LPN began falling asleep standing up, crying loudly, moaning, and going back and forth to the bathroom frequently. They described the LPN leaning over the medication cart with eyes closed, legs giving out, and falling asleep on the counter in the nurse’s station and at the open medication cart. Staff stated that no residents on that station received their medications as ordered, that residents repeatedly called for their medications, and that the LPN could not stay awake to pull or pass medications, even with assistance from the nurse on the other station who tried to help with the medication pass. One CNA reported the LPN kept falling asleep while trying to sign the narcotics book and refused an ambulance when staff tried to get emergency help. Medication administration audit reports for Station B showed 25 residents with medications documented as missed and 5 residents with medications documented as administered late during this shift. The DON and Administrator later confirmed that there was no designated charge nurse on duty, that the impaired LPN remained responsible for resident care and medication administration until a replacement nurse arrived around 3:00 AM, and that the DON was not notified of the situation until approximately 1:30 AM.

Removal Plan

• Coffee machines were removed out of service by the Maintenance Director.
• Individual pots of coffee will be made in the kitchen and temperatures of the pots will be monitored by the Dietary Department to ensure that the coffee served is at or below 140 degrees Fahrenheit.
• Coffee temperature logs were created that indicate the staff member who tested the temperature of the coffee, the time, and the date.
• Coffee temperature logs will be turned into the Administrator daily.
• Training for all staff prior to their next scheduled shift.
• No staff will be allowed to work until completion of training provided by the Administrator, DON, and Staff Development Nurse.
• Staff will be trained on accidents and supervision including implementing immediate interventions.
• Staff will be trained on abuse and neglect reporting and investigation.
• Staff will be trained on the hot liquids policy.
• Staff will be trained on notification of the Administrator and Director of Nursing (DON) of unusual occurrences, high risk events, and timely notification.
• Staff will be trained on charge nurse delegation and duties including assignment of charge nurse by the Scheduling Coordinator and Staff Development Nurse.
• If the assigned charge nurse calls off, the off-going charge nurse will notify the DON for the next assignment.
• The DON and Administrator's phone numbers are posted on the Facility Assignment Grid.
• In the event that the charge nurse is impaired, the DON and Administrator will be contacted.
• The Facility Assignment Grid was updated to include assignment for a designated charge nurse.
• Staff will be trained on medication administration documentation.
• All residents were evaluated for safety with hot liquids by the DON, Resident Care Coordinators, and RNs.
• The Administrator and DON were inserviced by the Director of Operations on conducting thorough investigations including root cause analysis and timely reporting to the State Agency.
• The Facility Assessment was updated to include a contingency plan for absence of supervisory nursing staff and adequately identified staffing needs by shift and building.
• The facility's Assignment Grid was updated to reflect who the charge nurse would be each shift.
• The Scheduler and the Staff Development Nurse were inserviced by the DON on the new Assignment Grid and charge nurse delegation.
• The Scheduler and/or Staff Development Nurse will designate on the Assignment Grid who the charge nurse will be.
• All resident records were reviewed for adverse effects from missed medication by the Corporate RNs with none found.
• Emergency Quality Assessment and Assurance Committee Meeting held.
• The Hot Liquid Policy, Medication Administration Policy, and Sufficient Nursing Policy were reviewed with no changes recommended or made.
• The Attorney General Office and the Mississippi Board of Nursing were notified by the Administrator of the incident involving LPN #1.
• LPN #2 was reported to the agency that she works for and is not allowed to work at this facility.