Bedford Care Center of Picayune

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure resident medications were protected from misappropriation for one (1) of four (4) medication carts.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide necessary care and services to protect residents from neglect when Resident #1 sustained a burn from hot coffee on 12/31/25 at approximately 3:40 PM and the facility failed to implement safeguards or supervision to protect other residents from exposure to the same hazard. Residents continued to have access to hot coffee in the dining room without supervision, temperature controls, or access restrictions until 1/12/26. Additionally, on the night shift beginning at 7:00 PM on 12/29/25, residents on Station B remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties. Despite staff observations of impairment, the nurse remained responsible for resident care until approximately 3:00 AM on 12/30/25. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to immediately report allegations of neglect to the State Agency for two (2) of (2) events reviewed. The facility's Administrator became aware on 1/6/26 that Resident #1 had sustained a burn from hot coffee on 12/31/25 and residents continued to have access to hot coffee without safeguards in place to prevent additional injuries until 1/12/26. The facility also failed to report to the SA when the Administrator became aware on 12/30/25 that an impaired licensed nurse had remained responsible for resident care from 7:00 PM on 12/29/25 until approximately 3:00 AM on 12/30/25 and medication administration could not be verified as accurate and timely. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to conduct thorough and timely investigations and failed to implement corrective actions to prevent further neglect for two (2) of (2) events reviewed. Resident #1 sustained a burn on 12/31/25 at approximately 3:40 PM; however, the facility failed to determine the root cause of the injury or implement safeguards to prevent additional residents from exposure to the same hazard, and residents continued to have access to hot coffee without supervision, temperature controls, or access restrictions until 1/12/26. Additionally, residents remained under the care of an impaired licensed nurse from 7:00 PM on 12/29/25 until approximately 3:00 AM on 12/30/25. Medication administration could not be verified as accurate and timely. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure the resident environment remained free of accident hazards when Resident #1 sustained a burn with blisters from hot coffee on 12/31/25 at approximately 3:40 PM and the facility failed to implement environmental controls or supervision to prevent other residents from exposure to the same hazard. Despite staff knowledge that hot coffee posed a burn risk, coffee pots remained accessible to residents in the dining room without supervision, temperature controls, or access restrictions until 1/12/26. This deficient practice affected one (1) of four (4) sampled residents (Resident #1) with the potential to affect all residents who drink hot coffee. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure sufficient licensed nursing supervision and coordination of care when no licensed nurse was designated to serve as charge nurse for the night shift beginning at 7:00 PM on 12/29/25. The scheduled charge nurse called in sick, and no replacement charge nurse was designated. As a result, no licensed nurse was assigned responsibility to supervise staff, coordinate care, or respond to unsafe conditions. During this shift, residents on Station B remained under the care of an impaired licensed nurse who was unable to safely perform nursing duties, and leadership was not notified until approximately 1:30 AM on 12/30/25, with the impaired nurse not replaced until approximately 3:00 AM for one (1) of seven (7) shifts reviewed. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure the facility assessment dated [DATE] was updated appropriately and failed to identify staffing and supervisory needs by shift and failed to ensure individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. The facility assessment did not include contingency planning for absence of supervisory nursing staff and did not ensure onsite licensed supervision when the scheduled charge nurse was absent. On the night shift beginning at 7:00 PM on 12/29/25, the scheduled charge nurse called in sick, and no replacement charge nurse was designated. As a result, there was not a licensed nurse assigned the responsibility to supervise staff, coordinate care, or respond to unsafe conditions. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to maintain complete and accurate medical records to document the services provided for four (4) of (4) sampled residents (Residents #1, #2, #3, and #4). Specifically, review of the Medication Administration Records (MARs) for the night shift of 12/29/25 revealed multiple medications were not documented as administered and medication administration could not be verified as accurate and timely.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a required Significant Change PASRR (Preadmission Screening and Resident Review) for 1 (one) of 23 (twenty-three) sampled residents (resident #113) after the initiation of an antipsychotic medication. The facility's failure to complete the Significant Change PASRR prevented the appropriate evaluation of the resident's mental health needs and compliance with federal PASRR requirements. A record review of the Level I PASARR dated July 9, 2019, was completed prior to admission. A review of the admission Record revealed Resident #113 was admitted to the facility on [DATE], with a diagnosis of chronic systolic heart failure. A subsequent review of the admission Record revealed the resident was diagnosed with unspecified psychosis not due to a substance or known physiological condition on May 15, 2025. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan with appropriate interventions for a resident diagnosed with a urinary tract infection (UTI) for one (1) of 23 sampled residents, Resident #7.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to store medications in a safe and secure manner for two (2) of four (4) medication carts reviewed.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure an advance directive, specifically a durable Power of Attorney (POA), was available and readily retrievable by facility staff for one (1) of 32 residents reviewed for advance directives. (Resident #100). This deficient practice had the potential to affect all residents who had a durable POA. Findings Include: A review of the facility's policy, Residents' Rights Regarding Treatment and Advanced Directives, revised 11/1/22, revealed, Policy: It is the policy of this facility to support and facilitate a resident's right to .formulate an advance directive. Definitions: Advance Directive is a written instruction, such as a . durable power of attorney for health care .Policy Explanation and Compliance Guidelines .3. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to revise comprehensive care plan interventions related to oxygen therapy (Resident #3), pain management (Resident #103), and trauma-informed care (Resident #62) for three (3) of 21 sampled residents.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to discard expired foods and failed to label opened foods with a use-by date for one (1) of three (3) kitchen observations.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store an O2 (Oxygen) nasal cannula and a nebulizer mask in a designated container and failed to change or discard a disposable humidifier water bottle timely for one (1) of two (2) residents reviewed for oxygen therapy.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure triggers and resident specific interventions were identified and initiated for a resident with Post Traumatic Stress Disorder (PTSD) for one (1) of 21 sampled residents.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to discard expired stock medications for one (1) of five (5) medication storage areas reviewed.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to provide hand hygiene for residents prior to meals for one (1) of four (4) dining rooms observed. Dining Room C.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to notify the Physician or the Resident Representative (RR) when a resident was observed to have bruising, edema, and pain to her left thigh and vaginal area, until the following day when she was diagnosed with a femoral fracture for one (1) of six (6) sampled residents. Resident #1.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect as evidenced by Resident #1, who was observed to have bruising, edema, and pain to her left thigh and vaginal area, did not receive care or treatment until the following day when she was diagnosed with a femoral fracture for one (1) of six (6) sampled residents. Resident #1.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to report an injury of unknown origin within two (2) hours when facility staff observed a Resident who had bruising, edema, and pain to her left thigh and vaginal area for one (1) of six (6) sampled residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions related to pain and resident transfers for one (1) of six (6) residents reviewed for care plans. Resident #1. Findings Include: Record review of the facility's Comprehensive Care Plans policy, revised 8/24/22, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights .to meet a resident's medical, nursing .needs that are identified in the resident's comprehensive assessment .Policy Explanation and Compliance Guidelines .3. The comprehensive care plan will describe .a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . [...]

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure a resident was free of accidents and/or hazards when a staff member transferred a resident using a mechanical lift without two (2) people to assist for one (1) of six (6) sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure pain management was provided to a resident when the resident was observed with bruising, edema, and pain to the left thigh and vaginal area, and was subsequently diagnosed with a femoral fracture for (1) of six (6) residents reviewed for pain. Resident #1.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure residents had readily available and reasonable access to their personal funds, seven (7) days a week, for one (1) of 30 residents with personal fund accounts. Findings Included: Record review of the facility's Policy and Procedures Resident Trust, undated, revealed, .Access to Funds The residents shall have access to funds daily during normal business hours and for some reasonable time of at least two hours on Saturdays and Sunday unless approved otherwise by the resident council . On 08/15/22 at 08:39 AM, in an interview with Resident #35, he stated he has a trust fund at the facility, but he is not able to get any money on the weekends. If he wanted money for the weekend, he would have to request it on Friday. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for pain for two (2) of 19 sampled residents. Resident #20 and Resident #38. Findings Include: Record review of the facility's policy, Care Plans - Comprehensive with a review date of 8/2/22 revealed, Policy Statement An individualized Comprehensive Person-Centered Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Resident #20 On 08/16/22 at 1:31 PM, in an interview Resident #20, she stated that she frequently has back pain that requires her to take pain medication. Record review Resident #20's Order Summary Report with Active Orders As Of: 08/18/2022 revealed a Physician's Order dated 11/5/21 for Ultram Tablet 50 MG (Milligrams) . [...]