The Pillars Of Biloxi
THE PILLARS OF BILOXI in BILOXI, MS — inspection on February 24, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
According to Pharmacy the Oxycodone-Acetaminophen did not became available or delivered to the facility until 12/26/25, at that time, the nurse should have discontinue the Hydrocodone-Acetaminophen 10/300 mg. On 12/26/25 the nursing staff did not discontinue the Hydrocodone-Acetaminophen as directed. Resident #2 was receiving both medications on 12/26/25, 12/27/25, 12/28/25, and 12/29/25.
She revealed that according to the Controlled Drug Receipt/Record/Disposition Form revealed nursing staff continued to sign out and document administration of Hydrocodone/APAP 10/325 mg four times daily from 12/26/25 through 12/29/25 despite the discontinuation order.
The DON acknowledged the medication should not have been administered after the discontinuation date and confirmed this was not consistent with facility policy or accepted standards of medication administration.
She confirmed the expectation from her staff is that discontinued medications are immediately removed from active MARs and reconciled with controlled substance records to prevent continued administration.On 2/23/26 at 2:00 PM, during an interview with Registered Nurse (RN) #2, she confirmed that she administered both narcotic medications to Resident #2 because both were active and listed on the Medication Administration Record (MAR).
She stated she did not question the duplicate opioid orders at the time of administration and assumed the medications were intended to be given as documented.
RN #2 acknowledged that she did not verify whether the Hydrocodone-Acetaminophen had been discontinued upon receipt of the new Oxycodone-Acetaminophen order and confirmed she did not notify the charge nurse, pharmacy, or the DON regarding the duplicate narcotic therapy.
255093 02/24/2026
The Pillars of Biloxi 2279 Atkinson Road Biloxi, MS 39531
way that maximizes each resident's well being.
interview, record review, and facility policy review, the facility failed to ensure nursing services were
function in the capacity of a licensed nurse for approximately five and one-half (5 1/2) days after receiving notification of failure of the National Council Licensure Examination (NCLEX) nursing exam for one (1) of three (3) facility nursing staff reviewed.Findings include: A review of the facility's policy Compliance and Ethics - Risk Areas for Fraud and Abuse, revised [DATE], revealed .Resident Quality of Care.2. A.
Sufficient staffing - staffing is provided in sufficient numbers and with staff who have appropriate clinical training, licensure and/or expertise to meet the needs of residents. A record review Board of Nursing License Verification for GPN #1 revealed she had a License Type of LPN (License Practical Nurse) Temporary Permit that was issued on [DATE] and expired on [DATE]. A record review of the NCLEX-Practical Nurse (PN) Candidate Report, test date [DATE], results revealed GPN #1 had not passed the exam. A record review of the Board of Nursing website ww.msbn.ms.gov/licensure/applications-and-forms revealed Temporary Permits for New Graduates indicated .if the new graduate fails NCLEX, the temporary permit becomes invalid and the new graduate is no longer able to work off the temporary permit.A record review of the facility's Personnel Action Notice (PAN), dated [DATE], Graduate Practical Nurse (GPN) #1 was terminated on [DATE], due to did not pass state boards.A record review of the facility's Employee Time Cards revealed GPN #1 punched in on [DATE] at 6:50 AM and punched out on 7:16 PM, on [DATE] at 6:55 AM and punched out on 7:17 PM, punched in on [DATE] at 6:53 AM and punched out on 7:21 PM, punched in on [DATE] at 6:50 AM and punched out on 7:22 PM, punched in on [DATE] at 6:55 AM and punched out on 7:13 PM, and punched in on [DATE] at 6:52 AM and punched out on 11:07 AM.A review of GPN #1 staffing schedules and assignment sheets revealed GPN #1 was assigned a full resident assignment during the period [DATE] through [DATE] and functioned in the capacity of a licensed nurse. On [DATE] at 2:00 PM, during an interview with GPN #1, she confirmed that she was notified by the State Board of Nursing and issued a temporary graduate permit on [DATE], with an expiration date of [DATE].
She stated she took the NCLEX-PN on [DATE] and received notification from the State Board of Nursing on [DATE] that she did not pass the examination. GPN#1 confirmed she continued working as a licensed nurse at the facility after [DATE] despite receiving notice of the failed examination.
She stated she believed she could continue practicing under the temporary permit until its expiration date of [DATE].
She acknowledged she did not verify with the State Board of Nursing whether the permit remained valid after failing the exam, nor did she notify facility administration of the failed examination results.
She confirmed that between [DATE] and [DATE] she continued to function in the role of a licensed nurse, including administering medications, performing treatments, and documenting in the medical recordOn [DATE] at 2:30 PM, during an interview, the Director of Nursing (DON) confirmed she was not aware that GPN #1 failed the NCLEX examination on [DATE].
The DON stated she believed the temporary permit remained valid through [DATE].
She acknowledged the facility did not have a system in place to verify examination results with the State Board of Nursing and relied on the nurse to self-report results.
The DON confirmed that had she been aware of the failed examination, GPN #1 would have been immediately removed from the schedule, as practicing without a valid license or permit is not permitted under State law or facility policy.
She further confirmed that during the period following the exam failure, GPN #1 continued to administer medications, perform treatments, and document in residents' medical records.
The DON stated that upon learning of the failure, she assessed residents assigned to GPN #1 and identified no adverse outcomes.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.