The Pillars Of Biloxi
Inspection history, citations, penalties and survey trends for this long-term care facility in Biloxi, Mississippi.
- Location
- 2279 Atkinson Road, Biloxi, Mississippi 39531
- CMS Provider Number
- 255093
- Inspections on file
- 33
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at The Pillars Of Biloxi during CMS and state inspections, most recent first.
Two residents did not receive medications in accordance with physician orders and professional standards. One resident with lumbar disc degeneration and moderately impaired cognition continued to receive a discontinued narcotic (Hydrocodone-APAP) for several days after a new opioid (Oxycodone-APAP) was ordered and delivered, because both drugs remained active on the MAR and an RN administered both without questioning the duplicate opioid therapy. Another resident, comatose with anoxic brain damage and a PEG tube, returned from the hospital with orders to start nitrofurantoin (Macrobid) for a UTI, but the antibiotic was not transcribed and administered until five days later, despite the hospital discharge documentation specifying it should be started upon return.
A GPN continued to function as an LPN for several days after receiving notice of failing the NCLEX-PN, contrary to state Board of Nursing rules that invalidate a temporary permit upon exam failure. Time cards, staffing schedules, and assignment sheets showed the GPN worked full shifts with full resident assignments, administering meds, performing treatments, and documenting in medical records while unlicensed. The GPN did not notify facility administration of the failed exam or verify permit status, and the DON, unaware of the failure, relied on the nurse to self-report results and had no system in place to confirm exam outcomes with the Board of Nursing.
A resident was prescribed multiple antipsychotic medications, including Olanzapine and Haloperidol, for indications such as mood and psychosis, despite medical records only documenting depression and no other psychiatric or mood disorders. Staff interviews revealed that the pharmacist and nursing staff relied on general processes for associating diagnoses with medication orders, but the documentation did not support the clinical need for these antipsychotic prescriptions.
A resident with moderate cognitive impairment exited the facility unnoticed by pushing out a window screen and leaving through his room window. The resident, not previously identified as an elopement risk, was last seen by a CNA and later found outside by staff, wearing only shorts and no shoes. The facility's lack of adequate supervision and insufficient environmental safeguards on windows resulted in the resident leaving the building undetected.
A resident with a self-care deficit and hemiplegia fell and sustained a fracture due to a CNA not using the required sit-to-stand lift during a transfer. The CNA attempted a manual transfer because the lift's battery was uncharged, leading to the resident slipping and falling.
A resident identified as a fall risk sustained a mildly displaced fracture of the proximal right humerus after a CNA failed to use the prescribed sit-to-stand lift during a transfer. The resident's foot slipped, causing her to fall onto the CNA, who attempted to break the fall. The resident, with a history of hemiplegia and hemiparesis, was sent to the hospital for evaluation and treatment.
A resident identified as an elopement risk due to impaired safety awareness and wandering behavior exited the facility unsupervised. Despite being escorted to the therapy gym, the resident was later found missing and discovered one mile away. The care plan interventions to prevent wandering were not effectively implemented, as confirmed by interviews with facility staff.
A resident identified as an elopement risk exited a facility unsupervised, following another person out through a frequently used rehabilitation door. Despite being recognized as a wandering risk, the resident was left unattended in the therapy gym and was found a mile away. The facility's failure to implement effective supervision and monitoring led to this incident.
The facility failed to store food according to professional standards, with undated and unlabeled food items found in the kitchen, including expired thickened lemon-flavored water and overly ripe bananas. The CDM and DAS confirmed the responsibility for labeling and inventorying food items, and the Administrator acknowledged a lapse in protocol.
The facility failed to resolve resident council concerns related to housekeeping, laundry, and dietary issues over six months. Despite policy requirements, grievances were not reviewed or resolved in a timely manner, leading to resident dissatisfaction.
The facility failed to ensure a clean and comfortable environment for its residents, as evidenced by soiled privacy curtains in the rooms of two residents. Housekeeping staff are expected to check curtains daily, but this was not done, and the Administrator was unaware of the issue.
The facility failed to date a multi-use medication vial and improperly stored medications, food, and biohazard substances together in two medication rooms. Nurses were responsible for dating vials and discarding expired medications, but an undated vial was found. Additionally, a biohazard refrigerator contained food items and blood vials, posing a contamination risk.
The facility's QAPI Committee failed to sustain its program during leadership transitions, resulting in repeated deficiencies related to residents' rights/environment and investigations. The facility did not ensure a clean environment for two residents and failed to complete a thorough investigation regarding an injury of unknown origin for one resident.
A facility failed to thoroughly investigate an injury of unknown origin for a resident with bilateral pubic ramus fractures. The investigation did not include interviews with other nearby residents or external parties involved in the resident's care, leading to an incomplete understanding of how the injury occurred.
The facility failed to provide written notification of facility-initiated transfers to residents or their Resident Representatives (RR) for five residents. While phone notifications were made, written notifications were not consistently provided, as confirmed by staff interviews. The Administrator acknowledged the lapse, attributing it to a staff member's health condition.
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital for five sampled residents. Staff typically contacted families by phone but did not follow up with written notifications, and the Administrator acknowledged the deficiency.
The facility failed to review and ensure the accuracy of a PASARR for a resident with Bipolar Disorder. The PAS, completed by hospital staff, incorrectly indicated no major mental illness, and the BOM did not review it for accuracy upon admission.
A resident with Neuromuscular Dysfunction of Bladder and moderately impaired cognition was found without a leg strap to secure his indwelling catheter tubing, despite facility policy and care plan requirements. Multiple staff confirmed the absence of the device, highlighting a failure to follow the care plan and physician's orders.
The facility failed to provide adequate ADL care, specifically showers and baths, for two residents who required assistance. One resident was found with dried feces and a strong odor, while another had a strong urine odor and grime on his body. Staff did not follow up to ensure proper bathing, and there was a lack of documentation and notification of refusals.
A facility failed to secure the indwelling catheter tubing for a resident with a leg strap, as required by policy and physician's order. The resident, with a diagnosis of Neuromuscular Dysfunction of the Bladder and moderately impaired cognition, was observed without the necessary leg strap, confirmed by both a CNA and an RN.
A resident on contact isolation received meals with washable dinnerware instead of disposable items, contrary to facility policy. Staff failed to follow isolation protocols, leading to potential cross-contamination.
The facility failed to provide influenza and pneumococcal vaccines to four residents who had requested them. Despite having signed consents, the vaccines were not administered, and the issue was only discovered during a survey. The ADON/IP nurse and DON were unaware of the lapse until it was pointed out by the survey team.
The facility failed to provide effective pest control related to roaches over a four-day survey period. Observations included a large roach moving from the kitchenette to the dayroom where residents were eating lunch, and then into a resident's room. Staff and residents confirmed the presence of roaches, despite pest control efforts. The pest control technician suggested that the roaches might be coming from outside and recommended additional measures, but the facility had not reported the issue to the pest control service.
The facility failed to post the Daily Nurse Staffing information for three out of four days during the survey. The facility's policy mandates that sufficient numbers of staff be provided in accordance with residents' care plans and the facility assessment. The Director of Nursing (DON) confirmed that the posted staffing information was outdated and should be updated at the end of every shift to reflect the actual staffing numbers.
Failure to Follow Physician Orders for Narcotic Discontinuation and Timely Antibiotic Initiation
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with physician orders and professional nursing standards for two residents. For Resident #2, physician orders dated 12/17/25 directed initiation of Oxycodone-Acetaminophen 5-325 mg every six hours and discontinuation of Hydrocodone-Acetaminophen 10/325 mg once the new medication became available. Pharmacy records showed the Oxycodone-Acetaminophen was delivered on 12/26/25 at 8:00 AM. However, the Order Summary Report still listed both narcotic medications as active, and the December 2025 MAR documented administration of both Oxycodone-Acetaminophen 5-325 mg and Hydrocodone-Acetaminophen 10-325 mg from 12/26/25 through 12/29/25. The Controlled Drug Receipt/Record/Disposition Form further confirmed that Hydrocodone/APAP 10/325 mg continued to be signed out and administered four times daily during this period, despite the discontinuation order. Resident #2 had been admitted on 6/4/25 with diagnoses including intervertebral disc degeneration of the lumbar region and had a BIMS score of 12 on the 2/5/26 MDS, indicating moderately impaired cognition. During interview, the DON confirmed that the Hydrocodone-Acetaminophen should have been discontinued when the Oxycodone-Acetaminophen became available on 12/26/25 and that nursing staff did not discontinue the medication as directed. RN #2 stated she administered both narcotic medications because both appeared as active on the MAR, did not question the duplicate opioid orders, did not verify whether Hydrocodone-Acetaminophen had been discontinued, and did not notify supervisory staff or pharmacy about the duplicate narcotic therapy. For Resident #1, the deficiency centers on a delay in implementing a newly ordered antibiotic following return from the hospital. Progress notes showed the resident was transferred to a local hospital on 12/24/25 for non-reactive pupils, unequal pupil size, and feeling hot to the touch, and returned later that day on medication for a UTI. The hospital After Visit Summary dated 12/24/25 indicated a diagnosis of UTI and a new order to start nitrofurantoin (Macrobid). The facility’s Order Summary Report reflected a physician order for Macrobid 100 mg via PEG tube twice daily for UTI, but with an initial start date entered as 12/30/29 and later clarified to a 10-day course starting 12/30/25. The MAR showed that Macrobid was not administered until 12/29/25, resulting in a five-day delay from the time the order was received on 12/24/25. Resident #1 had been admitted on 10/22/24 with diagnoses including anoxic brain damage, and the 1/22/26 MDS documented the resident as comatose and in a persistent vegetative state with no discernible consciousness.
Unlicensed GPN Functioned as LPN After Failing NCLEX
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services were provided by qualified and appropriately licensed personnel, as required by facility policy and state regulations. The facility’s policy on Compliance and Ethics – Risk Areas for Fraud and Abuse states that sufficient staffing must include staff with appropriate clinical training, licensure, and/or expertise to meet residents’ needs. A graduate practical nurse (GPN) was issued a temporary LPN permit with a defined expiration date and later took the NCLEX-PN exam. The NCLEX candidate report showed that the GPN did not pass the exam, and the state Board of Nursing’s published guidance states that if a new graduate fails the NCLEX, the temporary permit becomes invalid and the individual may no longer work under that permit. Despite receiving notification of failing the NCLEX, the GPN continued to work in the capacity of a licensed nurse for approximately five and one-half days, as confirmed by time cards, staffing schedules, and assignment sheets. During this period, she was assigned a full resident assignment and continued to administer medications, perform treatments, and document in residents’ medical records. The GPN acknowledged she did not verify the status of her permit with the Board of Nursing and did not inform facility administration of her failed exam. The DON confirmed she was unaware of the failed exam, believed the temporary permit remained valid until its printed expiration date, and that the facility had no system to verify exam results with the Board of Nursing, instead relying on self-reporting by the nurse. As a result, nursing care was provided by an individual who did not hold a valid license or permit during the identified timeframe.
Antipsychotic Medications Prescribed Without Appropriate Clinical Diagnosis
Penalty
Summary
The facility failed to ensure that antipsychotic medications were prescribed with appropriate, clinically documented diagnoses for one of six residents reviewed. A resident was admitted with diagnoses including Major Depressive Disorder, Single Episode, Unspecified, but the medical record did not indicate any other psychiatric or mood disorders. Despite this, the resident received multiple orders for antipsychotic medications, including Olanzapine and Haloperidol, for various indications such as mood, psychosis, and major depressive disorder. The Minimum Data Set (MDS) assessments consistently listed only depression as a psychiatric diagnosis, with no documentation of psychosis or other psychiatric conditions that would warrant the use of antipsychotic medications. Interviews with facility staff revealed that the pharmacist did not consistently verify that a specific supporting diagnosis was present for each medication, relying instead on the fact that medications can be used for multiple conditions. The DON described a process where the physician provides a diagnosis with each new medication order, and nurses enter this information into the electronic health record, which prompts for an associated diagnosis. Orders are reviewed daily, and the MDS nurse and consultant pharmacist are responsible for verifying the accuracy of diagnoses, particularly for psychotropic medications. However, the documentation reviewed did not support the use of antipsychotic medications for the resident in question.
Failure to Prevent Resident Elopement Through Unsecured Window
Penalty
Summary
The facility failed to provide adequate supervision and ensure environmental safety, resulting in a resident with moderate cognitive impairment exiting the building unnoticed and unsupervised. The resident, who had a Brief Interview for Mental Status (BIMS) score of 8 and was not previously identified as an elopement risk, was last seen inside the facility by a CNA at 6:00 AM and was found outside by a staff member at 6:30 AM. The resident had physically pushed out and removed the window screen in his room, exited through the window, and was found approximately 130 feet from the building, wearing only shorts and no shoes. Staff interviews and record reviews confirmed that the resident had not exhibited wandering or exit-seeking behaviors prior to the incident. The nurse on duty had last seen the resident at 4:30 AM during medication administration and wound care, and a CNA redirected the resident at 6:00 AM when he was found attempting to enter another resident's room. At some point after this, the resident managed to open his window, remove the screen, and leave the facility without being detected by staff. The facility's policies required the environment to remain as free of accidents and hazards as possible and for residents to receive supervision and assistance devices to prevent accidents. However, the failure to identify the resident as an elopement risk and the lack of effective environmental safeguards on the windows allowed the resident to exit the facility unnoticed. This incident placed the resident and other vulnerable individuals at risk for serious injury, harm, impairment, or death, and was determined to be Immediate Jeopardy and Substandard Quality of Care.
Removal Plan
- The Registered Nurse escorted the resident into the facility and assessed him with no signs or symptoms of injuries with vitals within normal limits.
- The Director of Nursing was notified by the nurse supervisor that the resident was outside on the curb and escorted back into the building. DON instructed the nurse supervisor to transfer Resident #1 to the secured unit for increased observation; as well as using a current daily census to perform a head count on all residents, and all residents were accounted for.
- The Administrator was notified of the incident.
- The Administrator contacted the Maintenance Supervisor to inspect all windows.
- The Maintenance Director reported to the facility to inspect the windows, all doors, windows, and keypads were working properly.
- The Administrator notified the State Agency.
- Licensed Social Worker interviewed Resident #1; he stated he just wanted to get air, and the Licensed Social Worker found no psychosocial harm.
- The Maintenance Director placed L brackets on all resident windows, which are metal shaped so that the windows are unable to open greater than six inches.
- An Emergency Quality Assurance Performance Improvement (QAPI) meeting was held that included the Administrator, Medical Director, DON, Regional Director of Operations, Regional Nurse Consultant, Unit Manager, Infection Preventionist, and Staff Development. The QAPI team discussed the adverse event, reviewed the immediate actions taken, reviewed policy and procedures. No changes were made to the policies and procedures. It was determined through staff and resident interview Resident #1 exited the facility by opening the window and removing the screen and going out for air. It was determined the Maintenance Director placed L brackets on all resident windows, which are metal shaped so that the windows are unable to open greater than six inches.
- An in-service was conducted by the Administrator for all staff prior to their oncoming shift and via telephone on missing residents, elopement risk policies, whom and when to notify if there is a missing resident, elopement books and arm band placement on each resident.
- All windows were verified to be in proper working order by the maintenance supervisor. All windows were secured with L shape brackets to prevent residents from exiting the facility. Maintenance will perform weekly visual inspections for four weeks and monthly thereafter to ensure that all windows and screens are in proper working order.
- Elopement drills were completed on all shifts by the maintenance supervisor and Assistant Administrator. Drills will be continued weekly for four weeks and monthly thereafter and will be brought in for review and recommendations during monthly QAPI. Any findings will be addressed immediately by the Administrator and/or Director of Nursing.
- All staff will be in-serviced for elopement/wandering. No staff will be allowed to work until they have received the in-service.
- The Nurse on duty moved Resident #1 to the secure unit, every one hour checks were put into place and fresh air walks were initiated.
- 100% of all residents were assessed by the Licensed Practical Nurse to verify that anyone deemed at risk for wandering or elopement proper interventions were in place. In-house census of 146 residents reviewed at this time and there was a total of 58 residents deemed at risk.
- 100% audit completed for all care plans to verify that any resident deemed a wandering or elopement risk were identified and updated.
- The Licensed Social Worker assessed Resident #1 to determine that there were no findings of psychosocial harm.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for a resident identified as a fall risk, resulting in a fall that caused the resident to sustain a mildly displaced fracture of the proximal right humerus. The care plan for the resident, who had a self-care deficit and was diagnosed with hemiplegia and hemiparesis following a cerebral infarction, required the use of a sit-to-stand lift for transfers. However, during a transfer from bed to wheelchair, the Certified Nurse Assistant (CNA) did not use the lift because its battery was not charged and attempted to transfer the resident manually, leading to the resident slipping and falling. The incident occurred when the resident requested to get up to smoke, and the CNA, believing she could manage the transfer without the lift, proceeded without it. This decision was contrary to the care plan's specified intervention, which was designed to ensure the resident's safety during transfers. The fall resulted in the resident being sent to the hospital for evaluation and treatment, where a fracture was confirmed. The CNA acknowledged not following the care plan, which contributed to the resident's injury.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident identified as a fall risk, resulting in a mildly displaced fracture of the proximal right humerus. The incident occurred when a Certified Nurse Assistant (CNA) attempted to transfer the resident from her bed to a wheelchair without using the sit-to-stand lift as outlined in the resident's care plan. The CNA reported that the resident's foot slipped during the transfer, causing the resident to fall onto the CNA, who attempted to break the fall. The resident was subsequently sent to the hospital for evaluation and treatment due to bruising and swelling in her right hand, where x-rays confirmed the fracture. The resident involved had a medical history of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, which contributed to her being a fall risk. The CNA admitted to not using the sit-to-stand lift because the battery was not charged, which was a deviation from the prescribed care plan. This failure to follow the care plan directly led to the resident's fall and subsequent injury. The incident was witnessed by another staff member, and the resident was assessed and treated for her injuries following the fall.
Failure to Implement Elopement Risk Interventions
Penalty
Summary
The facility failed to implement care plan interventions related to wandering and elopement risk for a resident, which resulted in the resident exiting the facility unsupervised and unnoticed by staff. The resident, who had been identified as an elopement risk due to impaired safety awareness and wandering behavior, was escorted to the therapy gym but was later found missing. The resident was discovered approximately one mile from the facility, walking in a residential area. The resident had been admitted with a diagnosis of Altered Mental Status and was identified as a wanderer in the Minimum Data Set assessment. Despite this, the care plan interventions to distract and monitor the resident were not effectively implemented. The staff failed to follow the care plan, which included offering pleasant diversions to prevent wandering. Interviews with facility staff, including the LPN and DON, confirmed that the care plan was not followed as required. The LPN acknowledged that the resident was not initially identified as an elopement risk upon admission, but later evaluations indicated the risk. The DON emphasized the importance of individualized care plans and confirmed the failure to implement the necessary interventions to ensure the resident's safety.
Removal Plan
- Staff identified the resident was missing and initiated missing resident procedures.
- Code W (elopement) protocols were initiated to notify all staff to begin searching.
- Staff members were assigned by Administrator and DON to search inside and outside of the building.
- The resident was located approximately 1 mile from the facility and returned safely.
- A headcount was completed to account for all residents.
- The Nursing Home Administrator notified the state agency of the elopement.
- The resident was assessed by LPN #1 with no signs of injury.
- The resident was assessed by the LSW with no psychosocial harm found.
- The Administrator and DON checked all doors and keypads for proper functioning.
- The inside door code was changed for emergency exit only.
- Entrance and exit through the therapy door are now restricted to visitors and staff.
- The Administrator notified the Attorney General's office of the incident.
- A QAPI committee meeting was held to review the incident and actions taken.
- 100% facility staff in-service completed regarding elopement/missing resident policies.
- 100% of all residents assessed for elopement risk.
- Twenty-seven new residents were added to the elopement/wandering list.
- 100% audit performed of care plans for those identified for elopement risk.
- 100% audit of wandering residents book completed to ensure all pictures are current.
- Elopement drills were performed on all shifts.
- Outside keypad to therapy door disabled and removed.
- Entrance and exit through therapy door is restricted to visitors and staff.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised. The resident was brought to the therapy gym and left unattended, leading to her being determined missing shortly after. She was found approximately one mile from the facility, having exited through the rehabilitation door, which was frequently used by visitors and staff. The resident had been admitted to the facility with a diagnosis of Altered Mental Status and was initially not identified as an elopement risk. However, during her stay, she showed signs of improvement and began exhibiting wandering and exit-seeking behavior. A second wandering evaluation confirmed her as a wandering risk, but despite this, she managed to leave the facility unsupervised. Interviews and record reviews revealed that the resident exited by following another person out the door before it closed completely. The facility's policies on accidents and incidents, as well as emergency procedures for missing residents, were not effectively implemented, leading to the resident's unsupervised exit. The incident highlighted a lapse in supervision and monitoring of residents at risk for wandering and elopement.
Removal Plan
- Staff completed a headcount compared to the daily census and all residents were accounted for.
- The Nursing Home Administrator notified state agency of the elopement.
- The resident was returned to her unit, assessed by LPN #1 and full body audit was completed. No signs or symptoms of injury, face was noted to be flushed, and resident took fluids cooperatively. NP assessed resident on unit, ordered labs, and UA (resulted negative). NP contacted the psychological NP for medication after ruling out acute episode.
- The resident was assessed by the LSW (Licensed Social Worker) with no psychosocial harm found.
- The Administrator and DON checked all doors and keypads for proper functioning, all were secure with no issues found.
- Inside door code changed and will be used for emergency exit only. Entrance and exit through therapy door are now restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility.
- The Administrator notified the Attorney General's office of the incident.
- Quality Assessment and Performance Improvement (QAPI) committee meeting was held involving missing resident.
- 100% facility staff in-service completed by Staff Development Coordinator, ADON, and Housekeeping Supervisor began regarding elopement/missing resident policies prior to returning to work.
- 100% of all residents assessed for elopement risk by ADON and Staff Development.
- Twenty-seven new residents added to elopement/wandering list.
- 100% audit performed of care plans for those identified for elopement risk to include visual monitoring and arm bands conducted by Regional Nurse Consultant.
- 100% audit of wandering residents book completed by Social Services to ensure all pictures are current.
- Elopement drills were performed on all shifts (7A-3P, 3P-11P, 11P-7A) by the Director of Nursing and the Staff Development Coordinator and will continue for 4 weeks then monthly for QAPI review and recommendations.
- Outside keypad to therapy door disabled and removed. Inside door code changed and will be used for emergency exit only.
- Entrance and exit through therapy door is restricted to visitors and staff. All visitors must enter and exit through facility's main entrance. All staff must enter and exit through back door of facility.
Failure to Store Food According to Professional Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an observation of the kitchen, it was found that Refrigerator #2 contained undated portioned glasses of orange juice and apple juice, as well as trays of sweet tea without labels or dates. Additionally, there were opened cartons of thickened lemon-flavored water with no opened dates and one with an expired manufacturer's use-by date. The freezer contained three frozen pie crusts without use-by dates or manufacturer's dates. The pantry had five overly ripe bananas with discolored black peelings that were not intact, exposing the inside of the bananas. The Certified Dietary Manager (CDM) acknowledged these issues and stated that it was the responsibility of the person who opened the food items to label them with the date they were opened. The CDM also reported that she was responsible for inventorying foods for quality, which was typically done twice weekly when the food truck made deliveries to the facility. Monthly in-service training on food safety was also mentioned by the CDM. The Dietary Aide Supervisor (DAS) confirmed that it was the CDM's responsibility to inventory foods for expiration dates and that the person who opened a food item was responsible for putting an open date on that item. The DAS also confirmed that the kitchen dietary staff received monthly in-service training. The Administrator acknowledged a lapse in the protocol by the kitchen staff to monitor for unlabeled, undated, and expired food items and stated that she expected the staff to make a daily inventory of the kitchen foods to ensure food quality standards were safe for the residents.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure resident council concerns were resolved in a timely manner for six months. The facility's policy required grievances to be reviewed within 24 hours and a written decision provided within 10 working days. However, multiple resident council concerns related to housekeeping, laundry, and dietary issues were not addressed or resolved, as evidenced by the lack of dates, signatures, and resolutions on the response forms. Specific concerns included issues with toilet paper, trash removal, cleaning, laundry mix-ups, and food quality and flavor. During interviews, residents expressed frustration over the lack of follow-up on their complaints, particularly regarding the poor flavor of the food. The Activities Director admitted to not recording food complaints every month, believing the food quality had improved based on her own experience. She also failed to complete the Old Business section of the meeting minutes, which would have informed residents of the facility's efforts to resolve their concerns. The Dietary Manager confirmed receiving and discussing food-related complaints but did not provide resolutions. The Administrator and Director of Nursing acknowledged the residents' complaints about the food but were unaware of the ongoing issues, believing they had been resolved. The Administrator had not attended resident council meetings in several months and was unaware of the residents' dissatisfaction with the food. This lack of communication and follow-up resulted in unresolved grievances and dissatisfaction among the residents.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to ensure a clean and comfortable environment for its residents, as evidenced by soiled privacy curtains in the rooms of two residents. During an observation and interview, Resident #6's privacy curtain was found to have long, brown streaks, and Resident #6, who has moderately impaired cognition, was unable to determine how long the curtains had been soiled. Similarly, Resident #27's privacy curtain had several circular brown spots, and although Resident #27, who is cognitively intact, confirmed the curtain was soiled, he was unsure of the duration. Housekeeper #2 confirmed the soiled conditions of the privacy curtains for both residents and stated that housekeeping staff are expected to check all curtains daily and notify the floor technician when curtains need to be changed. The Administrator was unaware of the soiled curtains and stated that she expected the staff to maintain a clean and home-like environment for the residents. The facility's policy on Resident Rights emphasizes the importance of providing a homelike environment, which was not upheld in this instance.
Improper Storage and Labeling of Medications and Biohazard Substances
Penalty
Summary
The facility failed to provide an opened date for a multi-use medication vial and did not ensure that medications, food, and biohazard substances were stored separately in two of the four medication rooms. During an interview, a registered nurse stated that nurses were responsible for dating multi-dose vials upon opening and for checking and discarding expired or undated medications every shift. However, an observation revealed a vial of Acetylcysteine 20% in the Rehab medication room that had been opened without a date or resident's name, which the Director of Nursing confirmed should have been labeled and subsequently disposed of. Additionally, an observation in the Central Unit medication room revealed a refrigerator marked as Biohazard containing food items, Med Pass, and grape juice. A registered nurse placed vials of blood inside the same refrigerator, which was confirmed to be an unsafe practice due to the risk of contamination. The Director of Nursing confirmed that food products should not be stored in a biohazard refrigerator, as it poses a contamination risk.
QAPI Committee Fails to Sustain Program During Leadership Transition
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain its program during transitions in leadership and did not maintain implemented procedures or monitor interventions put in place in March 2022. This failure was evident in two recited deficiencies related to residents' rights/environment and investigations. Specifically, the facility did not ensure a clean and comfortable environment for two residents, as evidenced by soiled privacy curtains. Additionally, the facility failed to complete a thorough investigation regarding an injury of unknown origin for one resident, despite previous citations for similar issues in March 2022. During an interview, the facility's Administrator, who was not employed at the time of the March 2022 survey, confirmed that the interdisciplinary team met monthly for QAPI meetings to discuss high-risk issues and provide interventions. However, the Administrator admitted that the QAPI committee had not discussed the soiled privacy curtains or the pelvic fracture investigation because she was unaware of the issues and believed the investigation was thorough. This indicates a lack of effective communication and monitoring within the QAPI committee, leading to repeated deficiencies.
Failure to Conduct Thorough Investigation of Injury
Penalty
Summary
The facility failed to complete a thorough investigation regarding an injury of unknown origin for a resident who was transferred to the hospital and diagnosed with bilateral pubic ramus fractures. The facility's investigation included interviews with the resident's medical providers, staff assigned to the resident prior to the hospital transfer, and the resident's roommate. However, the investigation did not include interviews with other residents who resided near or on the same hall as the injured resident to identify potential instances of abuse from staff, visitors, or other residents. The Administrator confirmed that the facility was aware of the fractures but was unable to determine how or when they occurred. The Administrator admitted that she did not contact the ambulance service or the hospital to investigate if an incident during transport or at the hospital could have caused the fractures. Additionally, the resident's cognitive skills were severely impaired, which required a staff interview for cognition. The facility's failure to conduct a comprehensive investigation, including interviews with other nearby residents and external parties involved in the resident's care, led to the deficiency.
Failure to Provide Written Notification of Transfers
Penalty
Summary
The facility failed to provide written notification of facility-initiated transfers to the residents or their Resident Representatives (RR) at the time of the transfer for five of 28 sampled residents. The facility's policy on emergency transfers or discharges requires notifying the representative or family member, but this was not followed. For instance, Resident #24, who was admitted with Chronic Obstructive Pulmonary Disease, was discharged to an acute hospital without written notification to the resident or RR. Similarly, Resident #75, admitted with Nontraumatic Acute Subdural Hemorrhage, was transferred to a local hospital without written notification to the resident or RR. Other residents, including Resident #76 with Cerebral Palsy, Resident #81 with Chronic Obstructive Pulmonary Disease, and Resident #126 following Joint Replacement Surgery, also experienced similar lapses in written notification during their transfers to acute hospitals. Interviews with staff revealed that while phone notifications were made to the RRs at the time of hospitalization, written notifications were not consistently provided. The Social Services Director confirmed that phone calls were made to the families, but no written notifications were sent. The Business Office Manager admitted to mailing notifications but did not keep copies due to a medical condition that limited her mobility. The Administrator acknowledged the failure to provide written notifications, attributing it to the Business Office Manager's health condition, and confirmed that it was the facility's expectation to notify residents or RRs in writing when a resident is transferred to the hospital.
Failure to Provide Written Notification of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon transfer to a hospital for five of the 28 sampled residents. Specifically, Residents #24, #75, #76, #81, and #126 were transferred to acute hospitals without their representatives receiving the required written notification. The facility's policy, dated 4/25/23, mandates that residents and/or their representatives be informed in writing of the bed hold policy, but this was not adhered to in these cases. The medical records for these residents did not contain copies of the written notifications, and interviews with the residents' representatives confirmed that they did not receive such notifications. Interviews with facility staff, including the Social Services Director, Business Office Manager, and Administrator, revealed that the failure to provide written notifications was due to a lapse in the process. The Social Services Director and Business Office Manager indicated that they typically contacted families by phone but did not follow up with written notifications. The Business Office Manager cited a personal health condition as a reason for not keeping copies of the letters. The Administrator acknowledged the deficiency and attributed it to the Business Office Manager's health issues, stating that it was the facility's expectation to inform families of the bed hold policy at the time of transfer.
Failure to Review and Ensure Accuracy of PASARR for Resident with Major Mental Illness
Penalty
Summary
The facility failed to ensure a Preadmission Screening (PAS) received from the hospital was reviewed and accurate, and a Preadmission Screening and Resident Review (PASARR) was initiated for a resident with a major mental illness. The PAS, completed by the acute care hospital staff prior to discharge, incorrectly indicated that the resident did not have a major mental illness. The resident was admitted to the facility with a diagnosis of Bipolar Disorder, which was not reflected in the PAS. The Business Office Manager (BOM) admitted to not reviewing the PAS for accuracy upon the resident's admission, leading to the oversight.
Failure to Implement Comprehensive Care Plan for Catheter Management
Penalty
Summary
The facility failed to implement a comprehensive care plan intervention related to a securing device for indwelling catheter tubing for one of the sampled residents. Resident #53, who has a diagnosis of Neuromuscular Dysfunction of Bladder and a moderately impaired cognitive status, was found without a leg strap to secure his indwelling catheter tubing. This was confirmed through multiple observations and interviews with the resident, a CNA, and an RN. The resident reported not having a leg strap, and both the CNA and RN confirmed the absence of the device during their respective observations. The facility's policy and the resident's care plan both indicated that the urinary catheter leg strap should be checked every shift and replaced as needed. Despite this, the resident did not have the required securing device in place. The Director of Nursing and the Care Plan Nurse both acknowledged that the care plan should be followed and that all residents with a catheter should have a leg strap in place. The deficiency was further supported by a physician's order dated 1/17/24, which also specified the need to check and replace the urinary catheter leg strap every shift.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care, specifically showers and baths, for two residents who required assistance. Resident #53 was observed with a strong odor of feces and dried feces on his body, indicating he had not received proper bathing. Despite the resident not refusing a shower, the CNA chose to give him a bed bath instead. The resident reported not receiving a shower for a long time, and records confirmed he had only received two showers in the past 30 days. The LPN admitted to not following up with CNAs to ensure residents received their baths or showers, and there was no notification of refusals documented for Resident #53. The resident had a moderately impaired cognitive status due to Alzheimer's Disease and required assistance with personal care. Resident #74 was also found in an unsanitary condition, with a strong urine odor in his room and grime on his body. The resident's family had complained about the lack of showers and the resident's dirty appearance. The CNA confirmed that the resident was dependent on staff for bathing and showers but often refused to go to the shower. Despite this, the resident only received five showers or baths in the past 30 days, with minimal documentation of bed baths. The DON and Administrator acknowledged the complaints but were unaware of the missed documentation and the lack of proper bathing. The resident had a severely impaired cognitive status due to Hemiplegia and Cerebral Infarction. Interviews with staff revealed a lack of follow-up and accountability in ensuring residents received their scheduled showers or baths. The DON and Administrator expected staff to provide ADL care and notify the Resident Representative (RR) of any refusals, but this was not consistently done. The facility's policy required daily baths per schedule and immediate notification of any refusals, which was not adhered to in these cases.
Failure to Secure Indwelling Catheter Tubing
Penalty
Summary
The facility failed to ensure that the indwelling catheter tubing for a resident was secured with a leg strap, as required by the facility's policy and the physician's order. The resident, who had a diagnosis of Neuromuscular Dysfunction of the Bladder and a moderately impaired cognitive status, was observed without a leg strap securing his suprapubic indwelling catheter. Both a CNA and an RN confirmed that the resident did not have a leg strap and had not been known to wear one. During interviews, the Director of Nursing and the Administrator acknowledged that all residents with an indwelling catheter should have a leg strap to secure the tubing. The failure to provide the leg strap was observed during multiple instances, indicating a lapse in adherence to the facility's policy and the physician's order, which aimed to prevent catheter-associated urinary tract infections and other complications.
Failure to Follow Contact Isolation Protocols
Penalty
Summary
The facility failed to handle dinnerware in a manner to prevent the possible spread of infection for a resident on contact isolation. Resident #8, who was admitted with diagnoses including Extended Spectrum Beta Lactamase (ESBL) Resistance and other infections, was observed receiving meals with washable dinnerware and silverware instead of disposable items. This was contrary to the facility's policy for contact precautions, which mandates the use of disposable dinnerware and utensils to prevent cross-contamination. The Licensed Practical Nurse (LPN) and Certified Nurse Aide (CNA) involved did not notice or follow the isolation protocol, leading to the meal tray being placed back with other residents' trays and returned to the kitchen without any distinction. The Dietary Manager and Infection Preventionist were unaware of the resident's isolation status, indicating a communication breakdown. The Admission Nurse could not recall if she had notified the dietary department about the contact isolation for Resident #8. The Director of Nursing (DON) confirmed that the procedures were not followed, as items taken into an isolation room should not be removed and mixed with other items. The Administrator also expected staff to adhere to the infection prevention policies, which were not followed in this instance, leading to a potential risk of infection spread.
Failure to Administer Requested Vaccines
Penalty
Summary
The facility failed to provide influenza and pneumococcal vaccines to four residents who had requested them. Resident #17, admitted with Bipolar Disorder, had a signed consent for the pneumococcal vaccine dated 12/28/23, but there was no documentation that the vaccine was administered. Similarly, Resident #31, admitted with Chronic Obstructive Pulmonary Disease (COPD), had a signed consent for the pneumococcal vaccine dated 12/1/23, but no documentation of administration was found. Resident #48, admitted with Hypertension, had a signed consent for the influenza vaccine, but there was no documentation that the vaccine was given. Resident #137, admitted with Osteomyelitis, had a signed consent for the pneumococcal vaccine dated 3/11/24, but again, no documentation of administration was found. During interviews, the Administrator explained that the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) was responsible for keeping up with the immunizations of the residents. The Director of Nursing (DON) and the ADON/IP nurse admitted they were unaware that the immunizations were not up to date until the survey team brought it to their attention. The IP nurse confirmed that the admission clerk was responsible for giving consents to the admission nurse to make management aware that vaccines had been requested. The DON confirmed that all four residents had signed consents for vaccines, but the vaccines were not administered. The facility's policy stated that influenza vaccines should be provided from October through March 31st and pneumococcal vaccines should be given in a timely manner, which was not adhered to in these cases.
Failure to Provide Effective Pest Control
Penalty
Summary
The facility failed to provide effective pest control related to roaches over a four-day survey period. Observations included a large roach moving from the kitchenette to the dayroom where residents were eating lunch, and then into a resident's room. Interviews with staff confirmed the presence of roaches, with one LPN noting that pest control services had been in the facility a couple of weeks ago. A CNA also confirmed seeing roaches several times, despite pest control efforts. During a resident council meeting, residents complained about large roaches in the building, expressing fear due to their size. Another observation noted a large roach moving across the dining room floor, with a resident confirming occasional sightings of roaches coming from outside the building. The facility's pest control vendor's technician confirmed seeing roaches in several residents' rooms during a visit on 3/21/24 and had switched to a stronger pesticide. The technician suggested that the roaches might be coming from outside and recommended a blow out outside the building to prevent them from entering. However, the facility had not reported the issue with roaches to the pest control service. The Administrator confirmed that pest control services sprayed the facility monthly but had not reported any issues with roaches to the pest control service.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the Daily Nurse Staffing information for three out of four days during the survey. The facility's policy, reviewed in October 2022, mandates that sufficient numbers of staff with the necessary skills and competency be provided in accordance with residents' care plans and the facility assessment. On April 1, 2024, at 10:05 AM, the posted staffing numbers were dated March 31, 2024, and did not reflect the current date. On April 2, 2024, at 8:30 AM, the posted staffing numbers were still dated March 31, 2024. On April 3, 2024, at 8:15 AM, the posted staffing numbers were dated April 2, 2024, and did not reflect the current date. During an interview on April 3, 2024, at 8:16 AM, the Director of Nursing (DON) confirmed that the posted staffing information was outdated and should be updated at the end of every shift to reflect the actual staffing numbers.
Latest citations in Mississippi
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
A resident with epilepsy, skin infection, an upper arm wound, gastrostomy status, and moderate cognitive impairment was observed twice resting in bed with a lunch tray while the call light was not within reach—once on the floor under the bed and once hanging behind the mattress, out of sight. The resident reported being able to use the call light but not knowing where it was. Staff, including CNAs, an LPN, the DON, and the Administrator, stated that call lights are expected to be left within residents’ reach and that training and competencies address this requirement, but there was no specific written policy on call light placement.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment when a resident’s room contained odorous soiled linens left on the floor and later placed on furniture with clean clothing, and the bed was made with torn linens exposing the mattress. Other residents reported that housekeeping did not clean under beds, and multiple large dead roaches were repeatedly observed under several beds, with one resident stating he often disposed of dead roaches himself. Residents also reported refusing to use the north shower room due to dirty clothing, feces, and residue on shower chairs and floors; an observation confirmed the presence of soiled clothing, a soiled brief, and unidentified substances on the shower chair and floor, despite staff acknowledging that CNAs were expected to clean and sanitize the shower room after each use.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of roaches and other insects in multiple resident rooms and common areas. Surveyors found gnats and dead roaches under beds, while several residents reported seeing roaches on ceilings, walls, and floors, including roaches falling onto them at night and having to remove dead roaches themselves. A family member reported bringing her own roach spray due to concerns about roaches in a loved one’s room. During a Resident Council meeting, roaches were seen crawling across the floor, and residents stated that roaches were commonly observed throughout the building. Although the contracted pest control provider reported monthly service focused mainly on entry points and exterior areas and facility staff described processes for reporting pests, the persistent roach activity showed the program was not effectively preventing or controlling pests.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Failure to Protect Residents’ Right to Rest Due to Unmanaged Nighttime Yelling
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified and comfortable environment by not effectively addressing ongoing disruptive nighttime behaviors of one resident that interfered with other residents’ ability to rest. Resident #1, admitted with diagnoses including Psychosis and Dementia and a BIMS score of 4 indicating severely impaired cognition, had documented episodes of hollering and yelling during nighttime hours, as noted in progress notes on 3/12/26 and 3/13/26. Interviews with cognitively intact residents, Resident #2 and Resident #3 (both with BIMS scores of 15), revealed that they frequently experienced disrupted sleep due to Resident #1 yelling loudly at night, while the environment was generally quiet during the day. Staff interviews confirmed awareness of the pattern of behavior. CNA #1, who worked both day and night shifts, reported that Resident #1 frequently yelled and screamed at intervals throughout the night and was generally quiet and often slept during the day, with staff assisting the resident out of bed into a geri-chair during both day and nighttime hours. The DON acknowledged the facility was aware of Resident #1’s increased nighttime yelling and extended daytime rest, attributing it to the resident’s Dementia and Psychosis, and stated that interventions such as monitoring, repositioning, offering care, and attempts at redirection had not stopped the behaviors. The Administrator also confirmed awareness of concerns that nighttime noise from Resident #1 affected other residents’ ability to rest. Despite this awareness and ongoing complaints from other residents, the disruptive nighttime yelling continued, resulting in a failure to uphold residents’ rights to a dignified existence and a comfortable environment.
Failure to Ensure Privacy and Dignified Care During Incontinence Care and Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and provided privacy during care, as required by resident rights policies and skills checklists. The facility’s Nursing Facility Resident Rights policy guaranteed residents the right to be treated with dignity, courtesy, and respect, and to have privacy during personal care. Facility skills checklists for feeding and peri/incontinent care specified that staff should sit facing residents at eye level when feeding and provide privacy by drawing curtains and closing doors during incontinence care. For Resident #2, surveyors observed a CNA providing incontinent care without closing the resident’s room door and with the privacy curtain only partially drawn. From the surveyor’s position at the bottom right corner of the bed, it was possible to see into the hallway while the resident was uncovered and exposed. Resident #2’s records showed admission with diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status. A recent MDS assessment documented a BIMS score of 11, indicating moderate cognitive impairment, and that the resident was dependent for toilet hygiene. The CNA later confirmed awareness that incontinence care required provision of privacy and that she had been trained and competency-checked on this requirement. For Resident #3, surveyors observed a CNA assisting the resident with eating while standing over the resident rather than sitting beside her, contrary to the facility’s feeding skills checklist and training. The DON intervened during the observation and instructed the CNA that staff were to sit next to residents while assisting with eating. The CNA stated she had forgotten to sit beside the resident. Resident #3’s records showed recent admission with diagnoses of cerebral infarction (stroke), anemia, and hemiplegia and hemiparesis affecting the right dominant side, and a baseline care plan indicating the resident was dependent for eating. Other staff interviews, including with a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that staff were trained at least monthly on residents’ rights, respectful and dignified care, provision of privacy during incontinence care, and the expectation that staff sit beside residents when assisting with eating.
Failure to Maintain Accessible Call Light for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was maintained within reach as required by the facility’s feeding skills checklist. The skills checklist for feeding a resident specifies that staff must leave the call light within the resident’s reach after feeding. For Resident #2, surveyors observed on two separate occasions that the call light was not accessible. On one observation, the resident was awake in bed with a lunch tray on the overbed table, and the call light was found lying on the floor under the head of the bed. The resident stated he could use his call light but did not know where it was. On a subsequent observation, Resident #2 was again in bed with a lunch tray in front of him, and the call light was hanging behind the mattress at the head of the bed, out of his sight and reach. The resident again stated he could use the call light but did not know where it was. Record review showed the resident had epilepsy, an infection of the skin and subcutaneous tissue, an open wound of the left upper arm, gastrostomy status, and a BIMS score of 11 indicating moderate cognitive impairment. Staff interviews with CNAs, an LPN, the DON, and the Administrator confirmed that call lights were expected to be within residents’ reach and answered timely, and that staff had received in-service training and competency checks on leaving call lights within reach. The Administrator also confirmed there was no specific written policy regarding call light placement.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Maintain Infection Control Practices During PEG Tube and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not maintaining aseptic technique and not providing ordered dressing changes for residents with PEG tubes and a sacral pressure injury. Facility policies on infection control and clean dressing changes required wound care to be provided in a manner that decreases the potential for infection and cross-contamination, including removal of soiled dressings with gloves, discarding gloves, performing hand hygiene, and donning clean gloves before continuing care. The peri-care audit tool also required glove removal, hand hygiene, and re-gloving after peri-care. These standards were not followed during multiple observed care episodes. For one resident with a PEG tube and diagnoses including Alzheimer’s disease, functional quadriplegia, and gastrostomy status, surveyors observed the PEG tube site without a dressing and with a yellowish-brown substance beneath and around the external skin disk extending about one-fourth inch onto surrounding skin. A CNA and an LPN both confirmed there was no dressing in place and acknowledged the drainage at the site. The LPN stated PEG tube site care should be completed daily and as needed for increased drainage and acknowledged that, with no dressing and the amount of drainage present, there was no way to tell when the site was last cleaned. Record review showed a physician order, effective several months prior, for daily cleansing of the PEG tube stoma with normal saline, patting dry, and applying a dry drain dressing to avoid skin breakdown. For another resident with severe protein-calorie malnutrition and gastrostomy status, the PEG tube site was observed with thick brown, crusted substance beneath the external skin disk extending approximately one-half to three-fourths of an inch to the surrounding area. The resident reported the site had not been cleaned in about three days and later stated they might have to clean it themselves. Follow-up observations confirmed the site remained unclean with visible drainage, and an LPN and the DON both confirmed the presence of thick, brown drainage and that the site had not been cleaned in several days, despite an order for daily cleansing with soap and water, rinsing, patting dry, and leaving open to air or applying a dry dressing if drainage was present. In a separate observation involving a resident with a stage IV sacral pressure ulcer and severe cognitive impairment, a CNA provided peri-care for stool soiling, then immediately assisted with wound care using the same gloves worn during peri-care, without performing hand hygiene or changing gloves. The CNA, treatment nurse, DON, and ADON all acknowledged that hand hygiene and glove change should have occurred between peri-care and wound care and that this represented an infection control concern.
Failure to Maintain Clean Resident Rooms and Shower Facilities
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by its Resident Rights & Quality of Life Policy. For one resident, surveyors observed a bag of odorous soiled linens resting on the floor of the room, and the resident’s bed was made with a bedspread that had a football-sized hole exposing the mattress. The resident, who was cognitively intact with a BIMS score of 14 and had Type 2 Diabetes Mellitus, reported that it was not unusual for bags of soiled linens to be left on the floor and for bedding to be damaged. A CNA confirmed that soiled linens were commonly left in bags on the floor after morning care and that torn bedding should not be used, and later placed the bag of soiled linens on the resident’s furniture where his clean clothing was hanging. The resident remained upset the following day, and a dead roach was observed under his bed near the headboard. Additional deficiencies were identified in other resident rooms. One resident with End Stage Renal Disease and a severely impaired cognition (BIMS score of 5) reported that housekeeping did not clean under the bed; surveyors observed three large dead roaches under the bed, which remained there the following day. When the Housekeeping Supervisor later observed the room, five dead roaches were present under the bed, and he stated the area should not have been in that condition. Another resident, with a diffuse traumatic brain injury and a moderately impaired cognition (BIMS score of 10), reported frequently picking up and disposing of dead roaches himself because staff did not remove them, and a large dead roach was observed under his bed. The facility also failed to maintain a clean and sanitary north shower room. During a Resident Council interview, multiple cognitively intact and moderately impaired residents reported refusing to use the shower room due to cleanliness concerns, including observations of dirty clothing, feces, and residue on shower chairs and floors. A housekeeper stated that while she cleaned the shower rooms multiple times a day, CNAs were responsible for cleaning and sanitizing the shower room after each use and that she had observed occasions when CNAs failed to do so. A subsequent observation of the north shower room revealed soiled clothing, including a soiled brief, on a shower chair, a yellow fluid-like substance on the floor and shower chair, and a white powdery substance on the floor, with no staff present. The Social Services Assistant, DON, and Administrator each acknowledged that staff were expected to clean and sanitize the shower room after each use.
Ongoing Roach Activity Demonstrates Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its pest control policy dated 9/1/2014, which states the center will maintain an ongoing program to keep the building free of insects and rodents. Surveyors observed multiple instances of roach and insect activity in resident rooms and common areas. In one cognitively intact resident’s room, gnats were seen flying and a dead roach was later found under the bed near the headboard. Another resident’s room contained three large dead roaches under the bed on two consecutive days; this resident reported that roaches were regularly seen in the room, especially at night, crawling on the ceiling and falling onto him and his roommate, and that staff had been notified but he had not seen staff respond to assess or treat the issue. A third resident reported seeing roaches on the ceiling and under the bed and stated he often removed dead roaches himself because staff did not; a large dead roach was observed under his bed. A family member of another resident reported feeling it was necessary to bring her own roach spray due to concerns about roaches in the resident’s room and stated she was told she could not keep the spray in the room, expressing concern that the roach problem needed to be addressed. During a Resident Council meeting, two large roaches were observed crawling across the floor, and residents reported that roaches were commonly seen in rooms and common areas, including on walls, ceilings, and floors, particularly at night. The contracted pest control provider reported he provides monthly services, focusing on different areas each visit, primarily treating entry points and exterior areas, and stated he had not personally observed roaches and received only occasional complaints. Facility leadership, including the housekeeping supervisor, DON, and Maintenance Director, described expectations that staff report pest sightings and that pest control services are available monthly and as needed, but the ongoing presence of roaches and dead insects in resident rooms and common areas demonstrated that the pest control program was not effectively preventing or controlling pests.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
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