The Pillars Of Biloxi

Federal health inspectors cited THE PILLARS OF BILOXI in BILOXI, MS for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-08-21.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of THE PILLARS OF BILOXI.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.

Federal health inspectors cited THE PILLARS OF BILOXI in BILOXI, MS for a deficiency under regulatory tag F-F0585 during a standard health inspection conducted on 2025-08-21.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of THE PILLARS OF BILOXI.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Based on staff interview, record review, and facility policy review, the facility failed to ensure antipsychotic medications were prescribed for residents with appropriate, clinically documented diagnoses for one (1) of six (6) residents reviewed for unnecessary medications. Resident #157Findings include: A review of the facility's policy, Antipsychotic Medication Use, revised 10/2022, revealed, Policy Interpretation and Implementation 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.A record review of the admission Record revealed the facility admitted Resident #157 on 9/20/24 with diagnoses including Major Depressive Disorder, Single Episode, Unspecified.A record review of the Discharge Summary from an acute care hospital, dated 9/20/24, revealed Resident #157's Problem List/Discharge Diagnosis included Hemorrhagic Cerebrovascular Accident, Disorientation, Pulmonary Embolism, Acute Kidney Injury, and Wheezing.A

record review of the Diagnosis Report revealed Resident #157 had a diagnosis of Major Depressive Disorder, Single Episode, Unspecified with an onset date listed as 9/20/24. A record review of the Order Summary Report with an order date range of 9/20/24 through 8/31/25 revealed Resident #157 had Physician's Orders for Olanzapine (an antipsychotic medication), dated 9/20/25 for Mood, for Olanzapine, dated 10/9/24, for Psychosis, Olanzapine, dated 10/22/24 for psychotic disorder, Olanzapine, dated 11/7/24 for Major Depressive Disorder, Single Episode, Unspecified, and Zyprexa (Olanzapine), dated 1/9/25 for Major Depressive Disorder, Single Episode, Unspecified. Further review revealed Physician's Orders for Haloperidol (an antipsychotic medication), dated 1/14/25 for mood and Haloperidol, dated 10/22/24 for Psychosis.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/26/25 revealed Resident #157 had a diagnosis of Depression and there were no other psychiatric/mood disorders indicated.A record review of the Significant Change in Status MDS with ARD of 1/31/25 revealed Resident #157 had a diagnosis of Depression with no other psychiatric/mood disorders indicated.On 8/21/25 at 11:45 AM, in an interview with the pharmacist, he explained that his monthly reviews include evaluating appropriate diagnoses, potential interactions, and duration of therapy. He stated that he does not generally have concerns if the medical record does not contain a specific supporting diagnosis for a medication, because many medications can be prescribed for multiple conditions. On 8/21/25 at 1:32 PM, during an interview with the Director of Nursing (DON), she explained that when a physician provides a new medication order, the physician indicates the diagnosis associated with the medication. The nurse then enters the order into electronic health record, where a prompt appears requiring

the associated diagnosis. She stated that orders are reviewed each morning to ensure diagnoses are in place for new medications. She further explained that the Minimum Data Set (MDS) nurse reviews diagnoses for accuracy, and for psychotropic medications, the consultant pharmacist verifies that appropriate diagnoses are present.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Federal health inspectors cited THE PILLARS OF BILOXI in BILOXI, MS for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-08-21.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of THE PILLARS OF BILOXI.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.

Federal health inspectors cited THE PILLARS OF BILOXI in BILOXI, MS for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2025-08-21.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of THE PILLARS OF BILOXI.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.

Federal health inspectors cited THE PILLARS OF BILOXI in BILOXI, MS for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-21.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of THE PILLARS OF BILOXI.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.

Federal health inspectors cited THE PILLARS OF BILOXI in BILOXI, MS for a deficiency under regulatory tag F-F0867 during a standard health inspection conducted on 2025-08-21.

Category: Administration Deficiencies

The facility was found deficient in the following area: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of THE PILLARS OF BILOXI.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.

Federal health inspectors cited THE PILLARS OF BILOXI in BILOXI, MS for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-21.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of THE PILLARS OF BILOXI.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.