FULTON, MS. Licensed Practical Nurse #1 mixed potassium chloride liquid into thickened water and brought it to the resident's room with other medications. The resident drank part of the mixture and refused the rest. The nurse told her she would leave it at the bedside and try again later.
The nurse pushed her medication cart down the hall to the next resident's room, leaving the dangerous heart medication unattended on an overbed table.
When questioned about the practice, LPN #1 acknowledged it was unsafe since another resident could take it. She confirmed that potassium was dangerous for residents not needing extra potassium and should not have been left at bedside. She then discarded the medication.
The resident had severe cognitive impairment with a mental status score of three out of 15, according to her assessment from April.
This was not an isolated incident at Courtyards Community Living Center. On the same day, inspectors found a stomach medication capsule sitting in a medicine cup on another resident's bedside table. That resident also had moderate cognitive impairment.
"Medication should never be left at the bedside for a resident to take later," Director of Nursing confirmed during the May inspection. "This practice puts other residents at risk because anyone could come into the room and take the medication that was not prescribed for them."
The facility's pharmacist had conducted training just weeks earlier warning that medications are never to be left at bedside for residents to take later. LPN #1 had signed the attendance sheet for the April training.
But medication safety was just one problem inspectors documented during their three-day visit in May. Staffing shortages had left residents without basic hygiene care for days.
Resident #8 lay in bed wearing a white t-shirt, his fingernails half an inch long with brown substance underneath and jagged edges. He confirmed he preferred his nails trimmed short and kept clean.
The next day, he was still wearing the same shirt, now covered with food stains. He had not showered since Friday, May 16.
Certified Nursing Assistant #1 explained that nails were supposed to be cleaned and trimmed on shower days. Resident #8's shower days were Monday, Wednesday, and Friday. Due to a staffing shortage on Monday, he did not receive his shower during the day shift.
The assistant warned that Resident #8 could develop a nail infection or suffer a skin tear or even a staph infection due to the current condition of his nails.
Resident #53 faced similar neglect. He had quarter-inch facial hair and a mild odor when inspectors found him on Monday evening. His shower days were also Monday, Wednesday, and Friday, but he had not received his scheduled shower.
"I guess they don't have enough girls working today," he told inspectors. The facility normally shaved him during showers, and he preferred to be clean-shaven. "I hope no one has to get close to me today because I haven't had a shower since Friday."
Staff confirmed the problem. When a CNA called in sick, they pulled one of the shower aides to cover floor duties, leaving only one aide to handle showers for the entire building.
CNA #3 explained the system broke down regularly. On Monday, Wednesday, and Friday, odd-numbered rooms received showers. On Tuesday, Thursday, and Saturday, even-numbered rooms got theirs. But when staff called in, the remaining shower aide could only handle rooms one through ten during the day shift. Rooms eleven through twenty-one were supposed to get showers during the night shift.
The practice failed repeatedly. Linens were normally changed on shower days, so when residents missed showers, they also slept in dirty bedding.
The Director of Nursing acknowledged that staffing had been a problem, especially over the previous two weeks. Federal data confirmed the crisis. The facility's weekend staffing was flagged as "excessively low" in the most recent quarterly report.
Registered Nurse #1 had recently moved from her role as assessment coordinator to floor nursing due to staffing problems. "We struggle a little bit, but we make do," she said initially. Then she was more direct: "To say we are struggling is putting it mildly."
The facility had tried multiple recruitment strategies. They posted on social media, hosted job fairs, handed out flyers to local businesses and churches. Corporate held a recent job fair with no nursing or CNA applicants showing up.
"The pay scale for CNAs was low there and they were the backbone of the facility," RN #1 confirmed.
CNA #4, a shower aide, said she was pulled from the shower team to work the floor often due to staff call-ins. This left only one shower aide for the entire building, causing residents to miss shower days and other care.
The staffing crisis contributed to infection control failures as well. During medication administration, LPN #1 used a pill splitter to halve a vitamin B12 tablet for Resident #35. She placed her ungloved finger on half the tablet to hold it in the splitter, dropped the other half into the resident's medication cup, then picked up the remaining half with her bare finger and placed it back into the medication bottle.
She confirmed she should have disposed of the tablet or worn gloves to avoid contaminating medications in the bottle. She had attended training on infection control during medication pass just weeks earlier. The training materials explicitly stated: "Never touch any medication with your bare hands."
The facility also failed to follow enhanced barrier precautions during catheter care for Resident #55. Two CNAs performed the procedure without using required gowns and gloves designed to prevent the spread of drug-resistant organisms.
Neither CNA was aware that enhanced precautions should have been used during catheter care. CNA #1 acknowledged that not following the protocols could cause an infection for the resident.
The Director of Nursing confirmed the CNAs had been trained on enhanced barrier precautions and that failing to use them placed Resident #55 at increased risk for infection.
The facility's own policies required sufficient staff to provide care according to resident care plans. The policy stated the facility would provide "sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents."
But Resident #8 remained in the same food-stained shirt for days, his long dirty fingernails posing infection risks. Resident #53 went without shaving or clean bedding. Dangerous medications sat unattended where confused residents could reach them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Courtyards Comm Living Center from 2025-05-22 including all violations, facility responses, and corrective action plans.
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