Tupelo Community Care Center

Inspectors wroteBased on observation, staff and resident interviews, record review and facility policy review, the facility failed to ensure a call light was maintained within reach for a resident who was dependent for assistance for 3 (three) of 6 (six) residents reviewed. Resident #1, Resident #2 and Resident #5. Findings Include: Review of the facility policy Call Light/Call Pager Systems with effective date of 09/09/22 revealed, .The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room . An observation and interview on 06/10/26 at 9:55 AM revealed Resident #1 lying in bed in his room. He revealed that he had been having trouble with his call light, but he now had a clip attached to the call light cord and he kept it clipped to his clothes. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review, the facility failed to implement a fall care plan for Resident # 3 and failed to implement a fluid restriction care plan for Resident #87 for two (2) of 23 care plans reviewed. Findings Include: Review of a facility policy titled, Goals and Objectives, Care Plans, last revised September 2013, revealed the policy statement indicated that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. An observation conducted on 12/10/25 at 8:30 AM revealed Resident #3 in bed with three-quarter length side rails raised on both sides of the bed. [...]

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to ensure adequate accident prevention for one (1) of five (5) residents reviewed for accident hazards (Resident #3). The facility failed to ensure the resident's ordered three-quarter length side rail was maintained in the raised position while the resident was in bed, resulting in the resident rolling out of bed and sustaining a fracture. Findings Include:Review of a statement on facility letterhead revealed that Proper Name Care Center did not have a specific policy pertaining to accident prevention. An observation conducted on 12/10/25 at 8:30 AM revealed Resident #3 in bed with three-quarter length side rails raised on both sides of the bed. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure resident privacy was maintained during medication administration for a resident with a gastrostomy tube for one (1) of six (6) care opportunities observed. Resident #16Findings Include: Review of the facility policy titled Dignity with a revision date of 2/21 revealed under, Policy Interpretation and Implementation: . 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. [...]

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, each resident had the right to determine their end-of-life care and the facility failed to ensure the desired code status of the resident was reflected in the documentation for one (1) of 23 sample residents reviewed. Resident #10Findings include: Record review of the facility policy titled, Advance Directives, undated, revealed, It is the policy of the facility to respect the resident's right of self-directed care including the right to issue Advance Directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on the behalf of the resident when the resident lacks the capacity to do so. 1. Each competent adult has the right to control his or her own health care decisions. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to accurately complete section K of the Minimum Data Set (MDS) for one (1) of 23 minimum data sets reviewed. Resident #100. Findings Include: Review of the facility policy titled Certifying Accuracy of the Resident Assessment undated, revealed under, Policy Statement: All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Record review of the Weights and Vitals Summary for Resident #100 revealed the following documented weights: 10/08/25 252 pounds10/28/25 252 pounds11/03/25 249.6 pounds11/13/25 230.8 pounds11/18/25 230.7 pounds Record review revealed Resident #100 has a significant weight loss of 21 pounds and -8.3% (percent) in 1 month. [...]

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to ensure fluid intake was managed, tracked, and documented in accordance with a physician ordered fluid restriction for a resident receiving dialysis for one (1) of six (6) resident reviewed for fluid restrictions. Resident #87Findings Include:Review of the facility policy titled Encouraging and Restricting Fluids revised 10/10 revealed under, Purpose: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. The policy further revealed under, Steps in the Procedure: . 5. Record the amount of fluid consumed on the intake side of the intake and output record. Record fluid in MLs (milliliters). [...]

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to ensure meals were served in accordance with a resident's physician-ordered nutritional requirements for one (1) of four (4) residents reviewed for dining. Resident #87Findings Include:The facility provided a statement on letterhead that read, (Proper name of the facility) does not have a specific policy on therapeutic diet. During an observation on 12/09/25 at 8:06 AM, Resident #87 was observed sitting up in her wheelchair in her room with her breakfast tray in front of her untouched. The resident had 2 pieces of bacon, scrambled eggs, toast, water, and apple juice. Review of the meal ticket dated 12/09/25 revealed, Supplements: Nepro - 1 carton and under Notes; Add Nepro to all trays. The Nepro supplement was not on the meal tray. Resident #87 stated she only received it sometimes. [...]

Inspectors wroteBased on observations, staff interview, record review, and facility policy review, the facility failed to clean and disinfect a multi-use glucometer according to the manufacturer's instructions and the required wet contact time for one (1) of two (2) glucometers observed. Resident #16Findings Include: Review of the facility policy titled Assure Prism Multi Blood Glucose Monitor System: Use, Cleaning and Controls Policy undated, revealed under, Cleaning and Disinfecting the Assure Prism Multi Blood Glucose Monitoring System: 1. Follow standard precautions and the manufacture's disinfection procedures to clean and disinfect the meter. [...]

Inspectors wroteBased on record reviews, resident and staff interviews, facility policy review, the facility failed to ensure a resident's right to be free from abuse and reprisal by staff. Resident #1 was verbally abused and confronted by Licensed Practical Nurse (LPN #1) for reporting that she had not received pain medications in a time when Resident #1 asked for them. Resident #1 was one (1) of three (3) residents reviewed for abuse and neglect.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that staff were trained on dementia care prior to caring for residents with dementia for one (1) of three (3) survey days. Findings Include: Record review of a typed statement on facility letterhead, dated September 11, 2024 and signed by the Executive Director revealed (Proper name of facility) do not have a policy on training staff or competency of staff. Record review of a typed statement on facility letterhead, dated September 11, 2024 and signed by the Executive Director revealed (Proper name of facility) have not implemented training on Dementia Care. An interview on 09/10/24 at 11:05 AM, with Certified Nurse Assistant (CNA) #1 and CNA #2 revealed they had been working at the facility for about 4 months and had not been trained on dementia care. [...]

Inspectors wroteBased on observations, staff and resident interviews and record reviews, the facility failed to be administered in a way that allows it to use its resources effectively to ensure the wellbeing of its residents for three (3) of three (3) days of survey. Findings Include: This tag is cross referenced to F561, F584, F677, F725, F726, F758, F908, F924 & F947. Record review of a typed statement on facility letterhead dated September 11, 2024, and signed by the Executive Director revealed (Proper name of facility) do not have a policy on Administration or Administrative Staff. We have a job description for each employee position. Record review of the facilities Job Description with an effective date of 8/01/12 revealed Job Title: Executive Director . [...]

Inspectors wroteBased on observations, staff and resident interviews, record review and facility policy review, the facilities Quality Assessment Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place. This failure resulted in four recited deficiencies that was originally cited on the 5/18/23 recertification survey. The recited deficiencies were in the areas of failing to implement an Activities of Daily Living (ADL) care plan, assist residents with ADL's, monitor for side effects of psychotropic medications and place an infectious resident in contact isolation. The continued failures during 2 recertification's shows a pattern of the facilities inability to sustain an effective Quality Assurance Program. Findings Include: This tag is cross referenced to: [...]

Inspectors wroteBased on observation, staff interview and facility letterhead review, the facility failed to ensure the handrails on the resident's halls were permanently affixed to the wall for four (4) of 4 hallways. Findings Include: Record review of a typed statement on facility letterhead, dated September 11, 2024, and signed by the Executive Director revealed the (Proper name of facility) do not have a policy on facility repairs. An observation on 09/09/24 at 11:49 AM, of all resident halls revealed multiple loose hand rails with the ends of the hand rails not being permanently affixed to the walls on all four halls of the facility. An interview and observation on 9/9/24 at 12:00 PM with the Administrator confirmed that the hand rails on the resident halls had been loose for a while. She admitted that they had been talking about replacing them, but she wanted to get the floor replaced first. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that new hire staff were trained on dementia care prior to caring for residents with dementia for one (1) of three (3) survey days. Findings Include: This tag is cross referenced to F 726, Competent Staff Record review of a typed statement on facility letterhead, dated September 11, 2024 and signed by the Executive Director revealed (Proper name of facility) do not have a policy on training staff or competency of staff. An interview on 09/10/24 at 11:05 AM, with Certified Nurse Assistant (CNA) #1 and CNA #2 revealed they both had been working at the facility for about 4 months and had not been trained on dementia care. [...]

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review, the facility failed to ensure a developed care plan was implemented for shaving (Resident #43), bathing (Resident #59), incontinent care (Resident #68, 351, & 352), and nail care (Resident #151) for six (6) of 24 resident care plans reviewed.

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review the facility failed to provide assistance with Activities of Daily Living (ADL's) for residents that were dependent on staff, as evidenced by not being shaved (Resident #43), missed bath (Resident #59), not performing timely incontinent care (Resident # 68, 351 & 352) and long dirty nails (Resident #151) for six (6) of seven (7) residents reviewed for ADL's. Resident #43, 59, 68, 151, 351 and 352.

Inspectors wroteBased on observation, resident/family/staff interviews, and record review, the facility failed to ensure nursing staff provided the necessary resident care for six (6) of seven (7) residents reviewed for Activities of Daily Living (ADL) during the survey. Resident #43, #59, #68, #151, #351, #352 Cross-Reference to F 677

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure residents were free from unnecessary drug use as evidenced by no side effect monitoring for the use of psychotropic medications for three (3) of 64 residents receiving psychotropic medications. (Resident #44, #54 and #87)

Inspectors wroteBased on observation, resident and staff interview, record review, and facility review the facility failed to help prevent the transmission of infections when a resident returned from the hospital with a treatment for Clostridium Difficile Colitis (C-Diff) infection was not placed on contact isolation precautions for one (1) of 14 residents being treated for an infection.

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review the facility failed to ensure a resident received coffee, as desired, for one (1) of 24 residents sampled.

Inspectors wroteBased on observation, staff interview, and facility review, the facility failed to provide housekeeping services necessary to maintain a clean home-like environment for one (1) of 55 rooms observed for a clean environment.

Inspectors wroteBased on resident/resident representative interviews, staff interview, record review, and facility policy review the facility failed to notify the resident/resident's representative(s) of a notice of discharge/transfer to the hospital in writing and in a language and manner they understand for one (1) of three (3) hospital transfers reviewed.

Inspectors wroteBased on resident/resident representative interviews, staff interview, record review, and facility policy review, the facility failed to provide written notice of the bed-hold policy to the resident/resident representative for (1) one of (3) three residents bed holds reviewed.

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to accurately complete section N of the five (5) day Minimum Data Set (MDS) for one (1) of 24 sampled residents. Resident #22 Findings Include: Review of the facility policy titled MDS Assessment with a revision date of 6/23 revealed, Policy: The facility shall conduct interdisciplinary assessments using the MDS item sets as defined by Federal/State regulations. These assessments provide information on the resident's condition to facilitate development of an individualized plan of care is as a means by which the facility can track changes in a resident's status. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility failed to ensure a wheelchair was in good, safe condition for one (1) of 21 sampled residents' wheelchairs.

Inspectors wroteBased on observation, staff interviews and facility policy review the facility failed to ensure that a lock box was permanently affixed in two (2) of two (2) medication refrigerators observed.

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to develop and/or implement a care plan related to finger nails, shaving and medications for three (3) of 24 care plans reviewed. Resident #75, Resident #77, and Resident #99.

Inspectors wroteBased on observation, resident interviews, staff interviews, record review and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care including shaving and nail care for two (2) of 111 residents observed for ADL care.

Inspectors wroteBased on resident interview, staff interviews, and record review the facility failed to renew a prescription for pain medication for a resident with constant pain for one (1) of two (2) residents reviewed for pain.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure that an anti-anxiety, as needed (PRN), medication had a stop date for one (1) of four (4) residents reviewed for psychotropic medications.

Inspectors wroteBased on observation, staff interviews, and record review the facility failed to store respiratory equipment in a manner to prevent the possibility of infection, for three (3) of four (4) observations.

Inspectors wroteBased on resident, staff interviews and facility policy review, the facility failed to provide mail services to the residents on Saturday for five (5) of five (5) residents interviewed during the resident council meeting. This has the potential to affect all 111 residents.