Failure to Maintain Adequate Staffing Assessment and Contingency Plan During Influenza Outbreak
Summary
The facility failed to ensure its facility-wide assessment contained the required details regarding staffing needs by shift and by unit, and did not maintain an actionable contingency plan for staffing emergencies. The assessment only included hours per resident day (HPRD) rather than specifying the number of licensed nurses and CNAs needed per shift and per unit. During an influenza outbreak, the facility did not update the assessment or contingency plan to address the increased risk and staffing needs, and administrative staff were used to assist with care when a nurse called in sick, but no agency staff were used and no formal process was in place to secure additional coverage. On the night in question, only one nurse was responsible for 58 residents from midnight until 7 AM, resulting in missed medications and inadequate monitoring for residents on one unit. The administrator and DON were aware of the staffing shortage and attempted to contact other nurses, including those at sister facilities, but were unable to secure additional coverage. The administrator assisted at the nursing station, but the facility's contingency plan did not provide clear procedures for securing coverage during emergencies or staff call-offs, and no updates were made to the plan following the incident. The facility did not identify the influenza outbreak when three residents tested positive, did not initiate droplet precautions, notify the health department, provide timely antiviral treatment, or maintain outbreak surveillance and staff illness tracking. The facility also failed to use its QAPI program to identify and correct system failures in infection control and staffing during the outbreak. These failures resulted in the facility being unprepared for staff absences during the influenza outbreak, placing all residents at risk for serious illness, harm, impairment, or death.
Removal Plan
- The Administrator held an emergency Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse, and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for QAPI for any changes needed and as re-education in policy.
- The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies.
- Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building.
- The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist.
- Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies.
- The Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications.
- The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
- The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
- Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in-service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
- The Administrator reviewed policy on QAPI plan and policy for re-education purposes and to review new policy. The QAPI plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up QAPI meeting.
- The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
- The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
- The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
- The Administrator notified the Mississippi Department of Health of the flu outbreak.
- The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.
Penalty
Resources
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The facility did not update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed licensed nursing staff. The written assessment specified one RN for one day shift per week and projected a need for 10 LPNs across 24 hours, with detailed LPN coverage by shift, and stated it should be reviewed and updated as needed to guide staffing decisions. At the time of survey, the DON reported 36 residents in the facility, acknowledged that resident acuity was higher than when the assessment was completed, and stated that the actual pattern was two LPNs on the floor for the day shift and two LPNs for the night shift, with the DON, ADON, and MDS coordinator available only during weekday business hours. The DON identified a total of seven licensed staff available and stated that more staff were needed to work directly with residents, confirming that the facility assessment no longer reflected current resident needs or staffing resources.
The facility failed to complete an accurate, building-specific facility assessment to determine needed resources and staffing for its resident population, including many residents with dementia or cognitive impairment. The written assessment left the behavioral and cognitive acuity fields blank, did not describe how supervision needs for cognitively impaired residents would be met, and contained generic staffing ratios that did not account for 12‑hour shifts or explain how staffing levels were determined for each unit. Leadership interviews revealed that about half of the residents had dementia or cognitive impairment, there was no formal acuity measure in use, and nursing staff levels were insufficient to meet supervision needs, with reports that residents were getting hurt. The DSD, interim DON, and administrator all acknowledged that the assessment did not clearly address dementia care, supervision requirements, or a method to determine acuity for staffing.
The facility’s assessment failed to include required competencies for Activities staff assigned as smoking monitors. Activities personnel, including a Recreation Transporter, were responsible for assessing residents’ smoking practices and monitoring residents during smoking, including those on oxygen, but the facility-wide assessment did not specify the knowledge, training, or skills needed for safe smoking monitoring and oxygen safety. Although the Administrator reported that new smoking monitors receive training and are evaluated by demonstration, and that smoking was listed as a special care need in the assessment, the document did not detail the actual training requirements for this role, leading to a deficiency related to incomplete evaluation of staff competencies.
Surveyors found that the facility’s required assessment of resources did not include its secured dementia unit or the building’s wander guard system, despite the presence of a locked, camera-monitored unit with coded entry/exit doors and a capacity of 35 residents. Documentation showed criteria for admission to the secured dementia unit based on dementia diagnoses and wandering or elopement behaviors, and the assessment identified numerous residents with dementia, impaired cognition, and behavioral health needs, with staff trained in dementia care. However, the physical environment section of the assessment omitted any reference to the secure unit or wander guard system, which the Administrator later acknowledged as an oversight.
Facility Assessment did not match actual night shift staffing. The assessment stated Harmony Manor and Quail Corner each required an LPN on nights, with consistent staffing prioritized in the memory care unit, but the April schedule showed both units sharing one licensed nurse on multiple nights. The DON confirmed one nurse was responsible for all 32 residents on those nights and acknowledged the assessment needed to reflect the staffing schedule.
Surveyors found that the facility’s 2026 facility-wide assessment, completed with a census of 69 residents, listed only total full-time employees and did not evaluate resident acuity or define specific staffing needs for each shift for RNs, LPNs, MA-Cs, and CNAs. In an interview, the administrator acknowledged that the assessment did not include shift-specific staffing requirements and stated he believed the assessment met regulatory requirements.
Failure to Update Facility Assessment to Reflect Increased Resident Acuity and Staffing Needs
Penalty
Summary
The facility failed to update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed nursing resources. The written facility assessment dated 10/15/25 stated that one RN was needed for one day shift per week, including weekends, and projected a total of 10 LPNs needed to provide care in a 24-hour period. The assessment further specified that seven LPNs were needed for the day shift, five for the evening shift, and four for the night shift. The assessment document itself stated that it was to be reviewed annually and updated as needed, and that it was to be used to evaluate the resident population and determine the resources necessary to care for residents competently during day-to-day operations and emergencies, and to drive staffing decisions. At the time of the survey, the DON identified that 36 residents resided in the facility and reported that the acuity level of the residents was higher than it had been in October 2025 when the facility assessment was completed. The DON stated that the projected need for ten LPNs in a 24-hour period was not correct and described the actual staffing pattern as two LPNs working on the floor from 7 a.m. to 7 p.m. and two LPNs working on the floor from 7 p.m. to 7 a.m., with the DON (RN), assistant DON (RN), and MDS coordinator (LPN) available to assist with resident needs during business hours, five days a week. The DON counted a total of seven licensed staff members available and acknowledged that more staff were needed to work directly with residents given the current higher acuity, demonstrating that the facility assessment had not been updated to reflect the current resident population and resource needs.
Failure to Conduct Accurate Facility Assessment for Dementia Care and Staffing Acuity
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that accurately reflected the needs of its resident population, particularly residents with dementia or cognitive impairment, and the resources required to care for them. The written facility assessment dated 10/15/25 acknowledged that the facility accepted residents with Alzheimer’s disease and dementia and referenced behavioral symptoms and cognitive performance in its acuity table, but the corresponding number/average range of residents was left blank. Although the assessment’s services section referenced mental health and behavior needs, including care of individuals with cognitive impairment, it did not identify how the facility would meet the supervision needs of these residents. The assessment’s staffing plan section listed generic staffing numbers and ratios for licensed nurses (RN, LVN) and nurse aides (CNA, RNA), but it did not explain how these numbers were determined, did not reflect that nursing staff worked 12‑hour shifts, and did not describe a method for determining resident acuity to support sufficient staffing. The tables contained placeholders such as “1:x LN ratio” and “1:x ratio days/evenings/nights” without clear, building‑specific calculations or justification. The assessment also failed to describe how individual staff assignments were determined and reviewed to ensure coordination and continuity of care across units, and it did not specify the staffing needs on each resident unit for residents requiring increased supervision. Interviews with facility leadership confirmed that the written assessment did not match actual resident needs or staffing practices. At the time of survey, the census was 73 residents, with 27 residents documented as having a dementia diagnosis. The DSD, who was covering staffing, stated that approximately half of the residents had dementia or cognitive impairment and required more supervision, that there was no measure of resident acuity being done, and that the facility lacked sufficient nursing staff to meet supervision needs, resulting in residents getting hurt. The DSD further stated that the staffing numbers in the assessment were not personalized to the building, were inaccurate, and that she did not understand their origin. The interim DON and the administrator both acknowledged that staffing was a problem, that resident acuity should have been assessed and clearly reflected in the facility assessment, and that the assessment should have identified and assessed resident supervision needs, which had not occurred.
Failure to Include Smoking Monitor Competencies in Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that evaluated staff competencies necessary to meet resident needs, as required by regulation. Surveyors found that the facility’s assessment, dated 09/2025, did not include the specific knowledge, training, and skills required for Activity Aides who were assigned to monitor residents who smoke. Although the facility’s policy and assessment referenced identifying resident acuity levels, providing continuous care through consistency, and basing staffing plans on resident population and needs, the assessment did not address competencies related to safe smoking monitoring and oxygen safety for the Activities staff who were functioning as smoking monitors. During the abbreviated survey, it was determined that one of four smoking monitors lacked documented evaluation of competencies necessary to provide the level and type of care needed for residents who smoke. The facility had designated Activities staff, including a Recreation Transporter, to assess residents’ smoking practices and to monitor residents during smoking activities, including residents using oxygen. In an interview, the Administrator stated that newly hired smoking monitor staff receive specific training and are evaluated by demonstration on proper monitoring of residents in the smoking room and residents with oxygen, and that noncompliant resident smoking behavior prompts ongoing staff re-education. The Administrator also stated that smoking was identified as a special care need in the facility assessment and referenced under other special needs and services related to buildings, but acknowledged that the assessment did not elaborate on the actual training required for safe smoking monitoring, resulting in a deficient facility assessment under 10 NYCRR 415.5(h)(2).
Failure to Include Secured Dementia Unit and Wander Guard System in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to include its secured dementia unit and associated wander management system in the required facility-wide assessment of resources needed to care for residents during routine operations and emergencies. Surveyors observed over multiple days that the building contained a secured unit on the right side of the facility, accessible only by doors requiring numeric codes to enter or exit, with additional coded exits leading to an internal courtyard and the exterior rear of the building, as well as a vestibule with coded doors and an interior entrance button. The unit had three hallways with cameras feeding to a monitor at the secured unit nurses’ station and a capacity of 35 residents. Sensors for a wander guard system were observed throughout the building, including near exit doors, and the system was confirmed to be operational. Review of facility documentation showed that the facility had established criteria for admission to a secured dementia unit, requiring a dementia diagnosis and behaviors such as elopement or wandering that necessitated closer supervision. The facility assessment identified 130 licensed beds and common diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, impaired cognition, and other behaviors requiring intervention, with an average of 36 residents having behavioral symptoms and cognitive performance issues and 36 residents receiving special treatments for behavioral health needs. The assessment also stated that all staff receive competency training on caring for residents with dementia, Alzheimer’s disease, and cognitive impairments. However, in the section addressing physical environment and building/plant needs, the assessment did not identify the wander guard system or the existence of the secure unit. In an interview, the Administrator confirmed there was a secured dementia unit policy, acknowledged that the secure unit was not included in the facility assessment and stated this was an oversight, and also confirmed the facility’s capacity as 120 beds.
Facility Assessment Did Not Match Night Shift Staffing
Penalty
Summary
The facility failed to ensure its Facility Assessment accurately reflected current staffing needs. The Facility Assessment, updated 03/26/2026, stated the staffing plan included one licensed nurse on night shift for Harmony Manor and one licensed nurse on night shift for Quail Corner, and that consistent staffing would be prioritized in the memory care unit, with staffing levels not adjusted for low census or low acuity so resident needs would be met during call-ins and other staffing shortages. However, the April 2026 staffing schedule showed Quail Corner and Harmony Manor sharing a licensed nurse during night shift on multiple nights. During an interview on 04/24/2026, the DON stated that on Saturday, Sunday, Monday, and Tuesday nights, both units shared one licensed nurse during night shift, and that the nurse was responsible for all 32 residents in the facility. The DON confirmed the Facility Assessment indicated each unit required a licensed nurse during night shift and stated the Facility Assessment needed to be updated to reflect the staffing schedule.
Failure to Include Shift-Specific Staffing and Acuity in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that considered specific staffing needs for each shift in order to care for residents competently during routine operations and emergencies. The facility assessment dated 1/5/26 for the 2026 year, with a census of 69 residents, listed only the total number of full-time employees and did not include an evaluation of resident acuity or delineate required staffing levels by shift (day, evening, night) for RNs, LPNs, MA-Cs, and CNAs. During an interview on 4/22/26 at 3:40 PM, the administrator confirmed that specific staffing needs by shift were not included in the assessment and stated that he believed he had completed the facility assessment in accordance with requirements. No additional resident-specific clinical details or medical histories were provided in the report, and the findings focus solely on the omission of shift-specific staffing analysis and resident acuity considerations in the facility’s assessment documentation.
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